Employee Direct Deposit Authorization
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1EMPLOYEE DIRECT DEPOSIT AUTHORIZATION
Please print legibly and complete all sections. Failure to do so may cause this form to be returned to you.
Employee Name:
Social Security Number:
Client Name:
Bank or Credit Union Information
Circle Either NET PAY or SPLIT PAY and fill in bank or credit union information
NET PAY:
SPLIT PAY:
Represents TOTAL amount of Net Pay.
Represents either a $ amount or % of Net.
CHECKING
SAVINGS account.
CHECKING
SAVINGS account.
This is a
This is a
Bank Name:____________________________________
Bank Name:____________________________________
Bank Phone #:_________________________State:_____
Bank Phone #:_________________________State:_____
Account #:_____________________________________
Account #:_____________________________________
Routing & Transit #:______________________________
Routing & Transit #:______________________________
Amount of SPLIT Pay to this account $ OR %__________
Please verify above information with your bank or credit union
You can have your pay split between up to 4 separate accounts
By signing this form you agree to the following:
l
I authorize my employer to direct deposit my pay into the bank account specified above.
l
this authorization is to remain in effect until my employer receives written authorization from me to change or terminate.
l
I grant my employer the right to correct any electronic funds transfer resulting from an erroneous overpayment by debiting
my account to the extent of such overpayment. If sufficient funds are not available in my account, I authorize my employer
to withhold such overpayment from one or more subsequent paychecks.
PLEASE NOTE:
1.
It can take from 2 to 4 pay periods after receipt of your Direct Deposit form for your Direct Deposit to become
effective.
2.
If this form is a change in your current direct deposit, you may receive one to two actual checks while your new
information is being processed.
3.
Funds transferred by electronic transmission will normally post to the account on your pay date. However, some
banks and credit unions may post up to 2 to 3 days after your pay date. Check with your bank or credit union.
4.
You are responsible for verifying that your funds are deposited and available for use prior to writing checks or
making withdrawals from your account.
Signature of Employee
Date
Please Attach Voided Check (DO NOT USE DEPOSIT SLIPS)
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Parent category: Business