Fillable Form 3-02 - Direct Deposit Authorization Form printable pdf download

Form 3-02 - Direct Deposit Authorization Form

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Form 3-02

CENTRAL COMMUNITY UNIT SCHOOL DIST. #3

DIRECT DEPOSIT AUTHORIZATION

I hereby authorize Central Community Unit School Dist. #3, to initiate credit entries via ACH to

my checking account and/or savings account indicated below and the depository financial

institution named below to credit the same to such account. One account may be a set amount

and the remaining balance will be deposited into my second account or I may choose to have one

deposit account only.

In the event a substantial error is made to my account I will be notified immediately. I hereby

authorize Central Community Unit School Dist. #3 to initiate a debit entry in the event of a

substantial error as agreed between employee and district bookkeeper at time of notification.

This authority is to remain in full force and effect until Central Community Unit School Dist. #3

has received written notification of its termination in such time and in such manner as to afford

Central Community Unit School Dist. #3 and the Depository Financial Institution a reasonable

opportunity to act on it. I acknowledge that the origination of ACH transactions to my account

and/or accounts must comply with the provisions of U.S. law.

Pay stubs will be distributed by Central Community Unit School Dist. #3.

Employee Name (print) ___________________________________________________

Please print legibly and include a voided deposit slip.

Account #1:

Select One:

Checking

Savings

Amount to be deposited: $ ____________________

Depository Financial Institution Name_____________________________________________________

Address ______________________________________________________________________________

City ___________________________________ State ______________________ Zip Code __________

Bank Routing Number __________________________________________________________________

Account Number _______________________________________________________________________

Signed ____________________________________________________________Date _______________

Account #2: