Direct Deposit Authorization Form (Page 3 of 4) in pdf

Direct Deposit Authorization Form Page 3

Direct Deposit Authorization Form

Fill in the information below and bring the completed form along with a voided check from

your First State Bank and Trust account to your company’s payroll department.

(please print)

Company Name ____________________________________________________

Employee Name ____________________________________________________

Address __________________________________________________________

City ________________________________ State ________ Zip ____________

Social Security # ______________________ Date of Birth __________________

Bank Routing #

081517907

Phone Number ________________________

My First State Bank and Trust Checking Account # _____________________________

I hereby authorize and request you to: Deposit my pay each pay period, effective

immediately, and begin depositing to the above account number at First State Bank and

Trust.

Additional Direct Deposit to:

CKG / SAV Account # _____________________ Amount _________________

(circle one)

CKG / SAV Account # _____________________ Amount _________________

(circle one)

Signature of employee ___________________________ Date ______________

If you receive a Social Security or Government Check,

the easiest way to enroll in Direct Deposit or switch

a Direct Deposit is to call the number below:

For Social Security/SSI Checks: 1-800-772-1213

For Veterans Benefits: 1-800-827-1000

Direct Deposit Authorization Form Page 3