Fillable Direct Deposit Enrollment / Change Form printable pdf download

Direct Deposit Enrollment / Change Form

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DIRECT DEPOSIT ENROLLMENT / CHANGE FORM

Employee Name: _______________________________________________________________

SSN: XXX-XX-_________

Bank Name

Account #

Account Type

I wish to deposit:

COMPLETE THE INFORMATION BELOW TO ENROLL OF CHANGE ENROLLMENT IN DIRECT DEPOSIT

Remainder of Net Pay

________ % of Net

Checking

Specific Amount $ _________

Remove from Direct Deposit

Savings

Remainder of Net Pay

________ % of Net

Checking

Specific Amount $ _________

Remove from Direct Deposit

Savings

ATTACH ONE OF THE FOLLOWING FOR EACH ACCOUNT INDICATED ABOVE.

Voided copy of a check

Deposit slip ( only if “ACH/RT” is displayed)

Bank letter or specification Sheet signed by a bank representative

EMPLOYEE AUTHORIZATION STATEMENT

I hereby authorize my employer to deposit my wages into the bank account(s) indicated on this form and initiate

(if necessary) debit entries or adjustments for any credit entries in error to my account. I attest that the associated

transactions authorized under this agreement will not be international ACH transactions (IAT). IATs shall include

credit or debit entries involving a financial agency (an entity authorized to accept deposits, transfer funds, or issue

money orders), if the office of financial agency that is involved in the payment transaction (holding accounts that

are debited or credited, receiving or making payments or serving as an intermediary in any part of the

transaction) is outside of the US.

EMPLOYEE SIGNATURE:

DATE:

COMPANY APPROVAL

COMPANY NAME:

COMPANY SIGNATURE:

DATE:

Direct Deposit Enrollment / Change Form

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