Direct Deposit/payroll Debit Card Authorization printable pdf download

Howell Public Schools

Direct Deposit/Payroll Debit Card Authorization

Employees have the option of receiving wages by Direct DE'po'sit

will

Seclion 1 BASIC INFORMATION

Employee name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

,SS#

(last

digits) _ _ _ _ _ _

~Effective

Date _ _ _ _ _ _ _ _

Seclion 2 PAYROLL ELECTION

Direct Deposit -_one bank or _one bank and credit union(s) elected for direct deposit (Please complete Sections 3 and 5 below)

PaYroll Dehit CarrlIP!f!mp rnmnlptp, Sprtinm: 4 and) hp.lnwl

Seclion 3 DIRECT DEPOSIT

Revise Deposit Amount

Entire Net Check

First National #072410550

~~~~:.:.:::~~~~~:~~ii:'.....:::.:.::..:.::::..~B~an~k~of~A~merica

# 072000805

Citizens Bank#072400528

Lake Trust Credit Union #272078268

Oakland Credit Union

#272479812

To help us avoid making an error, please attach a copyofa voided check .

• If you change banks, do not close your old bank account until your direct deposit has started at the new bank, which may take 2 pay periods,

Seclion 4 PAYROLL DEBIT CARD

Fedeiiil;;'requliesnnancrar~stffi'itIOOsto(;btai;,'"ven~and recordin1l)~arron"ih~rfdetitifie'seac"h~'person';r;-o~ope'ns~ail"acc7>unf In order for

Payroll to request a Payron Debit Card for you, we must provide all of the following information that will enable the financial institution to identify

If you do not submit a Direct DepositlPayroll Debit Card Authorization, Howell Public Schools will provide the necessary information and

you a Payroll Debit Card to pay your wages. For your protection, the financial institution may ask you to provide them additional

id:en'ifi"ati"on infonnation so they can verify your identity, You may choose to enroll in additional services available through the financial

institution, such as receiving paper statements, for which you may be charged a fee. Except for the routing and account number, Howell Public

Schools does not have access to any infonnation regarding your Payroll Debit Card account or transactions. On your first payday, you may pick up

new Payroll Debit Card, and a packet containing all of the terms and conditions, from the Payroll. You will then sign acknowledging that you

",ceive,d the Payroll Debit Card and packet. Your Payroll Debit Card will be reloaded on each payday you receive wages. You should contact the

institution with

Debit Card is lost or stolen.

_ _ _ _ _ _ _ _ _ _ _ M.I. ___ Last Name _ _ _ _ _ _ _ _ _ _ _

_=_~

Date of Birth _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ --:: _ _ _ _ _ _ --::c:-_ _ _ _ _ _ _ _

-:::-:-_-;:Social Security# _ _ _ _ _ _ _ _ _ _ _

State _ _ _ _ Zip _ _ _ _ _ _ _ _ Primary Phone _ _ _ _ _ _ _ _ _ _ _ _ _ _

Entire Net Check

Debit Card Routing # 231371579

Debit Card Account #

I have received my Payroll Debit Card, welcome brochure, program fees, program terms, conditions, and disclosures.

activating my Payroll

Debit Card, I am agreeing to the program terms, conditions, and disclosures that are included or made available to me from time to time from the

financial institution. I authorize the financial institution to debit my Payroll Debit Card account for the fees described in the fee schedule that is part

of the program terms, conditions, and disclosures,

Employee's Signature:

Date: _:-_ _ _ _ _ _ _ _ _ _ _

Section 5 AUTHORIZATION

I authorize Howell Public Schools to directly deposit my periodic wages/compensation payments, net of required tax withholdings; other required

with holdings or authorized deductions, into my account(s) as designated above and to initiate, if necessary, debit entries and adjustments for any

credit entries made in error to my account(s).

PrintName: ________________________ _

Employee's Signature:

--:c,-------=---=----:-=--=o:c-~_=__::_:____,__-

Date: _ _

-=-_-,-______ _