Fillable Adp Direct Deposit Setup Form (Page 2 of 2) in pdf

Adp Direct Deposit Setup Form Page 2

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ADP DIRECT DEPOSIT AGREEMENT FOR PREAUTHORIZED PAYMENT

PLEASE PRINT CAREFULLY IN CAPITAL LETTERS

DATE OF BIRTH

EMPLOYEE LAST NAME

EMPLOYEE FIRST NAME

EMPLOYEE SOCIAL SECURITY NUMBER

EMPLOYEE EMAIL ADDRESS

Full Payment Explanation of Benefits statements will not be provided without an email address.

John Benefit

5365

111 Sundry Drive

LaLa, CA 84564-001

BANKING INSTITUTE NAME

PAY TO THE

ORDER OF

CITY

FINANCIAL INSTITUTION

HOMETOWN, USA 12345

TRANSIT/ABA NUMBER

STATE

ZIPCODE

FOR

:123456789:

:12345678910:

5365

BANKING ACCOUNT NUMBER

ABA NUMBER

ACCOUNT NUMBER

CHECK NUMBER

EMPLOYEE AUTHORIZATION

I authorize ADP to initiate credit entries, electronically or by any other commercially accepted methods, and to initiate, if necessary, debit entries and adjustments for credit entries in error to my checking or savings

account and First Union to credit and/or debit the same to such account. I authorize ADP to debit my Flexible Spending or Reimbursement Account in the amount of $7.50 per failed transaction, if any of the account or

routing banking establishment information I provide to ADP is invalid, causing a rejection against my checking or savings account. This authorization will remain in full force and effective until written or electronic

notification has been received by ADP. After such notification, I will allow reasonable time for ADP to adjust my records accordingly.

EMPLOYEE SIGNATURE:_______________________________________________________DATE:______________

ACCOUNT TYPE (SELECT ONLY ONE)

PLEASE TAPE A COPY OF THE VOIDED CHECK OR DEPOSIT SLIP IN THE SPACE PROVIDED BELOW FOR VALIDATION OF INFORMATION

CHECKING

SAVINGS

ATTACH VOIDED CHECK (FOR CHECKING ACCOUNT)

OR DEPOSIT SLIP (FOR SAVINGS ACCOUNT) HERE

FAX COMPLETED FORMS TO 1-866-643-2219 OR MAIL TO:

Section A - must be completed to initiate processing.

ATTN Money Movement Department

11405 Bluegrass Parkway