Direct Deposit Authorization Form printable pdf download

DIRECT DEPOSIT AUTHORIZATION

Please complete this form and return to:

TMC - Payroll Department

5215 McPherson Rd.

Laredo, TX 78041

Part 1: Transaction Type

⁭ New Setup

⁭ Change financial institution

⁭ Cancellation

⁭ Change account number

⁭ I do not wish to participate (must fill out part 2)

⁭ Change account type

Part 2: Payee Identification

Employee Number

Location (Center Name or Regional Office)

1. Tax ID (Social Security Number)

2. Work Phone Number

3. Name

4. Home Phone Number

5. Street Address

6. City

7. State

8. ZIP Code

Part 3: Primary Financial Institution

9. Financial Institution Name

10. City

11. State

12. ZIP Code

13. Routing Transit Number

14. Customer Account Number

15. Type of Account

⁭ Checking

⁭ Savings

Part 4: Secondary Financial Institution

16. Financial Institution Name

17. City

18. State

19. ZIP Code

20. Routing Transit Number

21. Customer Account Number

22. Type of Account

⁭ Savings

Amount $

⁭ Checking

Amount $

Part 5: Authorization for Setup, Changes, or Cancellation

I hereby request and authorize TMC to deposit payments by electronic funds transfer into the account specified above and, if

necessary, debit entries and adjustments for any amounts deposited electronically in error. I recognize that, if I fail to provide

complete and accurate information on this authorization form, the processing of the form may be delayed or that my payments may be

erroneously transferred electronically. Please attach a voided check for the account to which the deposit is to be made. Write VOID

on the signature line.

This authorization will remain in effect until written notice to terminate is given. The undersigned must allow a reasonable amount of

time for initiating or terminating Direct Deposit and is responsible for notification of any change in financial institution.

23. Authorized Signature

24. Printed Name

25. Date

Revised 07/2008

C:\macfiles\update forms\Direct Deposit Authorization Form 07-08.doc

Direct Deposit Authorization Form

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