Direct Deposit/pay Card Cancellation Form

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DIRECT DEPOSIT/PAY CARD CANCELLATION FORM

DATE______________________

I______________________________________ request to cancel my Direct Deposit

(Employee name)

And/or Pay Card effective___________________________

(Effective date of cancellation)

MUST BE RECEIVED IN ACCOUNTING NO LATER THAN THE FRIDAY BEFORE

EFFECTIVE PAY DATE

Signed,

________________________________

(Employee Name - Printed)

________________________________

(Employee Signature)

18 Pelham Road | Salem, NH 03079 | 603.898.3000 office | 603.893.7000 fax

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