Direct Deposit Date: Employee Signup Form
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1USA Payroll Use Only
Client Number:
Employee Number:
Direct Deposit
PRS:
Employee Signup Form
Date:
Verified By:
Employee Instructions:
Employer Instructions:
1. Complete the “Employee - Required Information”
Complete the “Employer - Required Information”
1.
Section.
Section.
2. Complete the Direct Deposit, PayCard or both
2.
Return this form to USA Payroll to your Payroll
sections to specify where you want your earnings
Specialist.
deposited.
3. Retain a copy of this form. Return the original to
your employer.
I hereby authorize my employer, _______________________, (hereinafter COMPANY) to deposit any amounts owed me by
initiating credit entries to my account at the financial institution (hereinafter Bank) indicated below. Further, I authorize Bank to
accept and to credit my credit entries indicated by COMPANY to my account. In the event that COMPANY deposits funds
erroneously into my account, I authorize COMPANY to debit my account for an amount not to exceed the original amount of the
erroneous credit.
Employee - Required Information
Employer - Required Information
(Please PRINT)
(Please PRINT)
Employee Name: ____________________________
Company Name: __________________________________
Client Number: __________________
Complete for Direct Deposit
I would like my earnings deposited to the following bank account(s):
Bank Account #1
Bank Account #2
Checking
Savings
Checking
Savings
Bank Name:
Bank Name:
I wish to deposit (check one):
I wish to deposit (check one):
Entire Net Pay
_____% of Net Pay
_____% of Net Pay
Specific Dollar Amount $________.00
Specific Dollar Amount $________.00
Please attach one of the following (Check One).
Please attach one of the following (Check One).
Voided Check (deposit slips are not accepted).
Voided Check (deposit slips are not accepted).
Bank letter or specification sheet. *
Bank letter or specification sheet. *
*
*
See your local bank representative.
See your local bank representative.
This authorization is to remain in full force and effect until COMPANY and BANK have received written notice from me of its termination
in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
Employee Signature: _________________________
Date: _________________
Complete for Electronic Pay Stub
I would like to have my check stub sent to the following email address:
Electronic Check Stub Email Address: ________________________________ Password: __________________
(minimum of 4 letters or numbers)
Employee Signature: _________________________
Date: _________________
Complete to Cancel Direct Deposit
Effective _____________, I would like cancel direct deposit for the following account(s):
Checking (account # ___________________________)
% of Net Pay (account # _______________________)
Savings (account # _____________________________)
Specific Dollar Amt (account # __________________)
Employee Signature: _________________________
Date: _________________
Return this original form to your employer.
Rev 4/14
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Parent category: Business