Payroll Direct Deposit Request Form - Ymca Of The Rockies

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YMCA of the Rockies
Payroll Direct Deposit Request Form
To set up payroll direct deposit, please provide a VOIDED personal check or direct deposit
form issued from your financial institution; your email address; your authorizing signature;
and return to Human Resources. If you chose to write your financial institution name,
routing number, and checking or savings account numbers, please first verify the
information with your institution. Checking or savings account deposit slips cannot be
accepted.
_____________________________________________________________________________________________________________________
Attach ONE of the following:
 VOIDED personal check here
 Direct deposit form issued from financial institution
OR provide the following information:
Financial Institution Name: __________________________________________________________________
Routing Number: _______________________________________________________________________________
Account Number: _______________________________________________________________________________
_____________________________________________________________________________________________________________________
I authorize YMCA of the Rockies to deposit my payroll earnings directly into the named
account and understand that:
 direct deposit pay stubs will be sent electronically and securely to the email address
below, if provided, in which case I also consent to having my W-2 Wage and Tax
Statement accessible electronically to the same email address
 if there are any changes to my account information, it is my responsibility to notify
my Human Resources Office no later than the Friday prior to the next scheduled pay
date
 if a direct deposit is sent to an account which has been changed or closed without
notifying my Human Resources Office, or if the provided account information is
otherwise incorrect, a replacement check will be issued on the next scheduled pay
date and I may be charged a $30 processing fee
Employee name: ________________________________________________________________________________________________
Employee email: ________________________________________________________________________________________________
Employee signature: _______________________________________________________________ Date: ___________________
HR staff signature: ________________________________________________________________ Date: ___________________

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