Direct Deposit Form
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1DIRECT DEPOSIT FORM
1) Complete your employee information. (Please Print)
Employee Name _________________________________________________________ Social Security Number XXX -_XX_- __________
City / State:
__________________________________________________________
Employer / Client Name_____________________________________________________________________________________________
2) PRIMARY ACCOUNT – Make election
2) ADDITIONAL ACCOUNT (Optional) – Make election
□
□
□
□
□
□
New Account
Replace Existing Account
Stop Direct Deposit
New Account
Replace Existing Account
Stop Direct Deposit
Financial
Financial
Institution
Institution
City, State
City, State
9 Digit Routing Number
9 Digit Routing Number
Account Number
Account Number
Amount $
or
% to be deposited to this account
Amount $
or
% to be deposited to this account
□
□
□
□
Checking Account
or
Savings Account
Checking Account
or
Savings Account
Money Network Payroll Debit Card / Money Network Check
□ New Account □ Stop Account
Amount $_______________ or ___________ % to be deposited to this account
New routing and / or account number requests require a minimum of two weeks to become effective. Requests to stop direct deposit, or
change the amount / percentage will be effective on the first scheduled payroll after receipt by Employers Resource Management
3)
Sign, date, attach voided check(s) and return completed authorization form to your payroll contact.
I HEREBY AUTHORIZE EMPLOYERS RESOURCE AS PAYROLL AGENT TO INITIATE DEPOSITS (CREDIT) AND/OR CORRECTIONS TO PREVIOUS DEPOSITS TO
THE FINANCIAL INSTITUTION(S) INDICATED. THE FINANCIAL INSTITUTION(S) ARE HEREBY AUTHORIZED TO CREDIT AND/OR CORRECT AMOUNTS TO MY
ACCOUNT(S). This authority is to remain in full force and in effect until I either revoke it by forwarding a new Direct Deposit Authorization, or in the case of payroll deposits,
upon final payment of moneys due in the event termination of employment. I understand that I can access my pay statement electronically and this may be the delivery
method provided of my pay statement information.
Signature ______________________________________________________________________________ Date_____/_____/____
A COPY OF A VOIDED CHECK MUST BE ATTACHED
OpsForm-DirectDeposit-Oct-2012
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Parent category: Business