Direct Deposit Agreement Form printable pdf download

Direct Deposit Agreement Form

Check one:

___New Enrollment

____Change Account Information

___Delete from Program

Authorization Agreement

I hereby authorize Pro Tem Service to initiate automatic deposits to my account at the financial institution named

below. I also authorize Pro Tem Service to make withdrawals from this account in the event that a credit entry is made

in error.

Further, I agree not to hold Pro Tem Service responsible for any delay or loss of funds due to incorrect or incomplete

information supplied by me or by my financial institution or due to an error on the part of my financial institution in

depositing funds to my account.

This agreement will remain in effect until Pro Tem Service receives a written notice of cancellation from me or my

financial institution, or until I submit a new direct deposit form to the Payroll Department.

Checking Account Information

Name of Financial Institution:

Routing Number:

Account Number:

Signature

Authorized Signature:

Date:

Print Full Name:

Social:

Email for pay stub:

***Please attach a voided check or a direct deposit form from your financial

institution and return this form to the Payroll Department.***

Direct Deposit Agreement Form