Form 19407 - H-E-B Direct Deposit Authorization Form

H-E-B Direct Deposit Authorization Form

Complete the information below and return it to your Administrative Assistant for processing and retention at your work location. Allow 5-7 business days.

Your request may be delayed if all

information is not provided.

Please use black ink only and print legibly.

Notice

H-E-B utilizes a direct deposit process, utilizing NetSpend/reloadable card, HEBFCU or a Partners personal banking institution, for the payment of wages. I hereby

authorize and give H-E-B permission to begin the direct deposit of my payroll/wages to the account(s) I specify on the pay period following the date this form is processed:

______ I authorize payment of my wages through a NetSpend card or similar reloadable card instead of direct deposit.

(

Initials)

Name

Home Phone# (

)

-

PeopleSoft Employee ID

Work Phone # (

)

-

You must attach a deposit slip or voided check.

Dollar Amount or

Circle

Bank Name**

Percent to Deposit

Checking or

Circle One

9 Digit Bank Routing

Bank Account Number

Savings

*See Chart Below

Number

C

S

A C NC S

C

S

A C NC S

C

S

A C NC S

*A = Add

C = Change

NC = No Change

S = Stop

**Multiple transactions to the same bank should be handled through your Banking Institution (i.e. fund transfers between your checking & savings accounts).

Authorization

I authorize HEB Grocery Company and/or its parent or subsidiaries (“H-E-B”) to initiate direct deposit of my wages/pay to begin as soon as possible, or elect payment through a reloadable card

if indicated above, and/or initiate credit entries of my payroll to my direct deposit account(s) or NetSpend/reloadable card. I also authorize H-E-B to withhold or deduct from my wages/pay or

to withdraw, correct, or credit my direct deposit account(s) or NetSpend/reloadable card for the purpose of offsetting or correcting any prior entries or deposits, which were made to my direct

deposit account(s) in error or by mistake. I hereby release H-E-B of any and all claims, responsibility, fees, liability, and charges, including insufficient funds’ charges or fees, resulting from

or arising out of: i) any change, suspension, or cancellation of the direct deposit of my wages/pay; or ii) the withholding, deduction, or offset by H-E-B to my direct deposit account(s) or

NetSpend/reloadable card.

I understand that the amounts to be credited to my direct deposit account(s) or NetSpend/reloadable card are scheduled to be available to me each payday, except in unusual cases of delay in the

electronic banking system, which is a risk I willingly accept in exchange for the convenience of electronic banking. I agree that H-E-B has no responsibility for personal checks written against

my account(s).

Partner Signature ____________________________________________

Date ___________________________________

For Administrative Assistant Use Only:

Entered into PeopleSoft by: _____________________________________________

Date:__________________________________

***Retain form at work location***

Last revised on April 2012 Form # 19407