Direct Deposit Authorization Agreement Template

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Direct Deposit Authorization Agreement
Employee Name ___________________________
Employee # _____________________
I hereby authorize IASIS Healthcare to initiate credit entries to my account(s).
I also authorize, if
necessary, debit/credit entries, adjustments, or payroll deductions for any credit entries processed to my
account(s) in error. I acknowledge that the origination of ACH transactions to my account(s) must comply
with the provisions of U.S. law.
Add _____ Change _____ Stop/Cancel _____
Add _____ Change _____ Stop/Cancel _____
Name of bank, credit union, or savings and loan:
Name of bank, credit union, or savings and loan:
_______________________________________
_______________________________________
Checking ______ (OR)
Savings _______
Checking ______ (OR)
Savings _______
Routing/Transit Number____________________
Routing/Transit Number____________________
Account Number__________________________
Account Number__________________________
Fixed Amount $__________________________
Fixed Amount $__________________________
(OR)
(OR)
Percent of net pay amount ________________%
Percent of net pay amount ________________%
I acknowledge that payroll will verify the routing, transit, and account numbers on the first payroll
submission after authorization is given. This authorization is to remain in full force and effect until my
employer has received written notification from me of its termination and I have furnished updated
information to maintain a direct deposit. I understand that Direct Deposit changes can take up to 30 days
to complete.
Date______________ Employee Signature ______________________________________
Please attach a voided check or a printed document from your
financial institution indicating, the transit routing number,
account number, type of account (checking or savings), and
the account holder(s) name(s).
Note: Documentation cannot be hand written.
For Payroll Use Only
_______
Date Received ________ Date Entered _________
Received By __________
Entered By
10/23/13

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