Pay Selection Agreement Form printable pdf download

PAY SELECTION AGREEMENT

Acumen Fiscal Agent offers two pay receipt options.

You may choose either paycard or personal direct deposit.

Pay cards are available to every employee and are a convenient way to access your pay and

ensure that your pay will be available each payday morning without being at work to pick up

a paper check. To take advantage of the safety, dependability and convenience of pay cards,

check the paycard option below and sign the authorization statement.

Pay Card Option

_____ I choose to have my pay deposited directly to my paycard. My Money Network Visa

pay card and information kit will be mailed to my home address. My net pay will be

deposited onto the pay card each payday. I understand that I am responsible for notifying

Acumen when my pay card is activated. My pay card is not valid until this notification is

complete.

Direct Deposit Option

_____ I choose to have my paycheck deposited directly into my checking/savings

account. I will complete the Authorization for Direct Deposits and return to payroll along

with this Pay Selection Agreement.

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I hereby authorize Acumen Fiscal Agent, LLC. (here in after “Company”) to deposit any

amount owed to me for wages by initiation of credit entries to my account at the financial

institution (hereinafter “Bank”) handling my choice indicated above. Further, I authorize

Bank to accept and credit any 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. This

authorization is to remain in full force and effect until Company receives written notice from

me of its termination in such time and in such a manner as to afford a reasonable opportunity

to act on it.

Employee Signature_____________________________________ Date __________________

Name________________________________________________________________________

Adress_______________________________________________________________________

City_____________________________State___________________Zip__________________

Social Security Number_______________________________

Birth date ____/____/_______

Home Phone # ___________________________

Home Fax # ______________________

ALWAYS CHECK YOUR PAY STUB OR YOUR ACCOUNT TO VERIFY THAT YOUR

DEPOSIT HAS POSTED.

++++++++++++++++++++++For Payroll Use Only ++++++++++++++++++++++++++

Paycard ABA # 084003997

Paycard # ________________________________

Pay Selection Agreement Form