Direct Deposit Authorization Agreement Form printable pdf download

Direct Deposit Authorization Agreement Form

Direct Deposit Authorization Agreement

Please complete this form and attach a voided check if you wish to have your pay

directly deposited to your checking account. If you have a savings account please

attach a letter from your bank that states your routing number and account number.

WE DO NOT ACCEPT DEPOSIT SLIPS

This authorization will remain in effect until the company has received written notification from

me that it is to be terminated in such time and manner for the company to act on it.

Name on Account

Transit / ABA Number

Name of Bank/S&L/Credit Union/Other

Account Number

City, State, Zip (of Bank)

Account Type (Check one):

□

Checking Account

Savings Account

Any funds deposited to my account in error and not due me by PSU will be refunded to

PSU within 7 days of the deposit date.

I hereby authorize PSU to initiate deposits to my bank account indicated below.

Employee Information:

Print Name

Employee #

Social Security Number

Signature

Date

Please attach a copy of voided check or statement from bank for a savings

Deposit slips are not accepted

account

DIRECT DEPOSIT CANNOT BE PROCESSED WITHOUT THIS INFORMATION!

OFFICE USE ONLY

Direct Deposit

Set Up

to Begin

(Date)

(Ck. Date)

Direct Deposit Inactive

(Date)

Mail List □

Recurring Ded. □

PR Comment □

AAC52/8.08

Direct Deposit Authorization Agreement Form