Direct Deposit Enrollment Form - Affiliated Payroll Services printable pdf download

DIRECT DEPOSIT

ENROLLMENT FORM

Employee Information

Employer Information

PLEASE PRINT

Employee Name:_____________________

Employer Name:_____________________

Social Security Number: _______________

Federal ID Number: __________________

Complete for DIRECT DEPOSIT and attach a VOIDED check(s). Deposit Slips are not accepted.

Note: If depositing into a Savings Account ask your bank for for the Routing/Transit Number as the

number on the Savings Deposit slip may not be the same.

I authorize my employer to deposit my wages/salary to the following bank account(s).

Bank Account #1 Checking / Savings (Circle one)

I wish to Deposit (Check One):

Bank Name____________________________

Entire Net Pay

Routing Number ________________________

____ % of Net

Account Number________________________

Specific Dollar Amount $ _______

I authorize my employer to deposit my wages/salary to the following bank account(s).

Bank Account #2 Checking / Savings (Circle One)

I wish to Deposit (Check One):

Bank Name____________________________

Entire Net Pay

Routing Number ________________________

____ % of Net

Account Number________________________

Specific Dollar Amount $ _______

I authorize my employer to deposit my wages/salary to the following bank account(s).

Bank Account #3 Checking / Savings (Circle One)

I wish to Deposit (Check One):

Bank Name____________________________

Entire Net Pay

Routing Number ________________________

____ % of Net

Account Number________________________

Specific Dollar Amount $ _______

________________________

____________

Employee Signature:

Date:

By authorizing above, I agree that I am either the accountholder or have the authority of the accountholder to

authorize my employer to make direct deposits into the named account(s) above. Further, I agree that if my employer

deposits funds into my account in error they have the authority to remove those funds via an electronic transaction.

For Office Use Only

Date Received: ________________ Date Prenoted: _______________ Date Accepted:_______________

Comments:________________________________________________________________________________________

Direct Deposit Enrollment Form - Affiliated Payroll Services

Related Articles

Related forms

Related Categories