Employee Direct Deposit Enrollment Form

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Employee Direct Deposit Enrollment Form
Employee Direct Deposit Enrollment Form
To enroll in Direct Deposit, simply fill out this form and give it to your payroll department. In addition to this form,
please attach a voided check, not a deposit slip, for each checking account listed below. If depositing into a savings
account, ask your bank to give you the Routing/Transit number for your account as it isn’t always the same as the
number on a savings deposit slip.
Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.
Important! Please read and sign before completing and submitting.
I hereby authorize the City of Williston to deposit any amounts owed me, as instructed by my employer, by initiating
credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize
Bank to accept and to credit any entries indicated by the City of Williston to my account. In the event that the City of
Williston deposits fund erroneously into my account, I authorize my account for an amount not to exceed the original
amount of the erroneous credit.
This authorization is to remain in full force and effect until the City of Williston and Bank have receive written notice
from me of its termination in such time and in such manner as to afford the City of Williston and Bank reasonable
opportunity to act on it.
Employee Name: ____________________________
Social Security # : _______-_____-______
Employee Signature: _________________________
Date: ______________________________
Account Information
Please be sure to specify the amount or percentage to be deposited into each account if depositing into more than one
account. The total percentage must equal 100%
1. Bank Name/City/State: ___________________________________________________________________________
Routing/Transit #: ___________________________________
Account #: ___________________________________
Checking
Savings
Other
I wish to deposit $ _____.___ or
Entire Net Amount
2. Bank Name/City/State: ___________________________________________________________________________
Routing/Transit #: ___________________________________
Account #: ___________________________________
Checking
Savings
Other
I wish to deposit $ _____.___ or
Entire Net Amount
3. Bank Name/City/State: ___________________________________________________________________________
Routing/Transit #: ___________________________________
Account #: ___________________________________
Checking
Savings
Other
I wish to deposit $ _____.___ or
Entire Net Amount

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