Direct Deposit Authorization Form - City Of Claremont
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1DIRECT DEPOSIT AUTHORIZATION FORM
(No more than two deposit accounts may be set up.)
**NOTIFY PAYROLL IMMEDIATELY IF YOU CLOSE OR CHANGE BANK ACCOUNT**
TO BE COMPLETED BY EMPLOYEE:
I hereby authorize City of Claremont, NH to initiate credit entries and to initiate, if necessary, debit entries and
adjustments for any credit entries in error to my account indicated below and the depository name(s) below,
hereinafter called depository, to credit and/or debit the same as such:
EMPLOYEE NAME:__________________________________
______-____-______
(
)
(
)
Please print your name as it appears on your account
Social Security #
---------------------------------------------------------------------------------------------------------
_____ New Enrollment
_____ Cancel Enrollment
___________Change in Deposit Information
ACCOUNT TYPE:
___ Checking
___ Savings
(If checking/attach voided check)
FROM
: AMOUNT: $_________or/ NET __________
TO
: AMOUNT: $_________or/ Net__________
BANK:___________________________________ TELEPHONE #:(___)____-__________
ACCOUNT #:_____________________ BANK ROUTING _____________________
--------------------------------------------------------------------------------------------------------
_____ New Enrollment
_____ Cancel Enrollment
___________Change in Deposit Information
ACCOUNT TYPE:
___ Checking
__Savings
(If checking/attach voided check)
FROM
: AMOUNT: $_________or/ NET __________
TO
: AMOUNT: $_________or/ Net__________
BANK:___________________________________ TELEPHONE #:(___)____-__________
ACCOUNT #:_____________________ BANK ROUTING _______________
----------------------------------------------------------------------------------
EMPLOYEE ACKNOWLEDGEMENT
The authority is to remain in full force and effect until the company has received written notification from me of its
termination in such time and in such manner as to afford the company and depository a reasonable opportunity to
act on it. The City of Claremont reserves the right under NACHA rules to request a reversal within five days of the
original deposit date in cases of duplicate payments or erroneous payments.
EMPLOYEE SIGNATURE:__________________ DATE:_______________
TO BE COMPLETED BY PAYROLL ENTERED:____PRENOTE DATE:_________________;
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