Employee Direct Deposit Authorization Form printable pdf download

EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM

COMPANY NAME: _______________________________________________

Reimbursement Account Employee Direct Deposit Authorization Form

ST EPS FOR COM PLE TING TH IS FORM

Sign and date form.

Read Terms and Conditions

Complete all required information below

If the account is not in your name alone, have

the other account holder also sign and date form.

Attach MICR record or voided check (not deposit

slip).

6. Mail or fax to address on bottom of page.

Last Name

First Name

Social Security Number

Work Phone

−

Account Number

Routing Number

Typically, account numbers are 10 digits and routing numbers are 9 digits. See example below to locate the numbers on your voided check.

Check Action

Effective Date

Acct. Type

Ownership of Account

−

New

Change

Cancel

Month

Day

Year

Checking

Self

Joint

Other

-------------------------------ATTACH A VOIDED CHECK or MICR SHEET ----------------------------

DO NOT attach a Deposit Slip because deposit slips do not show the necessary information.

Joan Doe

Anywhere, USA

_____________________

$ ____

PAY TO THE ORDER OF

____________________________________

DOLLARS

YOUR TOWN BANK

VOID

YOUR TOWN

AR 123456

____________________________

_______________________________

FOR

‡

123456789

1234567891

Routing Number

Account Number

I certify that I have read and understand the Terms and Conditions on the back of this form. By signing this agreement, I authorize Aetna to initiate credit entries to the

Account(s) indicated above for the purpose of reimbursements from my Account(s) and to initiate, if necessary, debit entries and adjustments for any credit entries

made in error.

Signature:

Date:

__________________________________________________________

________________________

If the account is a joint account or in someone else’s name, that individual must also sign to indicate agreement with the statement above.

Signature:

Date:

_________________________________________________________

________________________

Please send all completed forms documentation to:

Aetna