Direct Deposit Agreement Form


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:
Authorized Signature:
Print Full Name:
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.***


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Parent category: Business