Direct Deposit Authorization And Agreement Form printable pdf download

Direct Deposit Authorization and Agreement

The undersigned (hereafter referred to as the “employee”) hereby authorizes and requests Paycom Payroll, LLC (“Paycom”) to

make credits and/or debits from time to time in the account(s) identified below and authorizes the bank and any other financial

institution to process such credits and/or debits. It is agreed that these credits and/or debits may be made electronically and

under the Rules of the National Automated Clearing House Association (NACHA). It is agreed that Paycom is only responsible

for the direct deposit of funds actually received, maintained and retained from employee’s employer, hereafter referred to as the

“employer.” Employer’s instructions to Paycom and employer’s use of Paycom’s services shall not violate the NACHA rules

or the laws of the United States.

NSF’s or Employer Withdrawals: In the event Paycom fails to receive and retain funds from the employer or in the event funds

are withdrawn from Paycom’s account by reason of insufficient funds, reversal, failure to authorize or otherwise, the

undersigned employee hereby authorizes Paycom to reverse or withdraw funds from employee’s bank account(s) designated

below or any other bank utilized by employee as reimbursement to Paycom. In any such event, employee shall be liable to

Paycom for all amounts paid to employee by Paycom, which have not been actually paid to and received by Paycom (and not in

any way reversed) from employee’s employer. Employee agrees to be liable for and to reimburse Paycom for any amounts

Paycom credits to employee’s account that are not actually received and retained by Paycom from employer. Employee hereby

agrees that Paycom is not his/her employer but instead a mere intermediary and that in the event the employer fails to fully fund

its payroll obligations, employee shall be liable to Paycom for any amounts Paycom credited from Paycom’s accounts to

employee’s account. Employee agrees that Paycom reserves the right to reverse direct deposit of funds paid in error. It is the

employee’s responsibility to verify funds deposited into such account(s) before performing transactions on those funds. Under

no circumstances shall Paycom be responsible for insufficient funds charges or any other charges posted to employee’s

account(s). By signing below, Employee agrees to the above terms. Employee further agrees to any Paycom Terms of Use for

Direct Deposit Services, as may be amended from time to time. In the event employee does not agree to the above terms,

employee should not sign this Agreement and should elect to be paid through ordinary check instead of using Paycom’s direct

deposit feature.

Attach a voided check or copy of a check for each account. (No deposit slips please). Indicate whether it is a checking or

savings account by circling the appropriate type of account.

Please call your bank and confirm the ACH Routing Number(s) and Account numbers for Checking and/or Savings.

Main Account (Net Pay) –

Checking or

Savings Account

(Check one)

Acct # ____________________________________________________

ACH Routing # /__/__/__/__/__/__/__/__/__/

Bank Name _________________________________________________________

Additional Account -

Checking or

Savings

Additional Account -

Checking or

Savings

(Check one)

Acct #__________________________________________

ACH Routing # /__/__/__/__/__/__/__/__/__/

Dollar Amount or Percentage________________________

Bank Name ______________________________________

Additional Account -

Checking or

Savings

Additional Account -

Checking or

Savings

(Check one)

Acct #__________________________________________

ACH Routing # /__/__/__/__/__/__/__/__/__/

Dollar Amount or Percentage________________________

Bank Name ______________________________________

Employee Name_______________________________________ Employee SS #_______________

Address______________________________________ City___________________ State_____ Zip _________

EMPLOYEE SIGNATURE: ___________________________________

DATE: _____________________

Direct Deposit Authorization And Agreement Form

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