Direct Deposit Authorization Note printable pdf download

Direct Deposit Authorization Note

Please complete this form and return it to the payroll department.

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Be sure to include a voided (Cancelled) check from your checking account and/or a deposit slip for your savings

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account, whichever is applicable. The details from the check / deposit slip will be used to verify the account

details.

You also have the option to deposit a part of your net pay into a secondary account, such as savings or credit

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union account. Please specify the dollar amount from your net pay that should be deposited in your secondary

account.

Name:

Your Bank / Financial Institution:

Social Security Number:

City/State

Primary Account Number

Secondary Account Number

Dollar Amount $

Please check the applicable option:

Checking

Savings

Checking

Savings

Pay Card

I authorize _______________________________________________ and the above Financial Institution to

deposit my net pay and/or flat amount automatically into my account(s) each payday, and to initiate any

necessary adjustments for entries made in error to my account.

(Signature)

(Date)

Attach Voided Check(s) / Deposit slip here.

Direct Deposit Authorization Note