Payroll Direct Deposit Form

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Payroll Direct Deposit Form
Check One:
New
Change an existing Account
New Account to add to existing account(s)
Cancellation (account#                                                     )
Effective Date:
Employee Name:
Employee SSN:
Employee Email:
NOTE:
The following MUST be attached to this form to setup new or additional accounts:                              
Checking Accounts:  A voided check                                                                                                                                   
Other Accounts:  Written proof of transit routing # AND account # from financial institution
Financial Institution Name:
Allocation Priority:             ___1                ___2                ___3                              
The order of deposit if you are depositing more than one account
Financial Institution Address:
Account Information:
Routing#:
Account#:
Type of Account:         ____Checking
____Savings
Check One:
____Full Deposit
____Amount to Deposit
____Percentage to Deposit
____Excess
$________________
%________________
Financial Institution Name:
Allocation Priority:             ___1                ___2                ___3                              
The order of deposit if you are depositing more than one account
Financial Institution Address:
Account Information:
Routing#:
Account#:
Type of Account:         ____Checking
____Savings
Check One:
____Full Deposit
____Amount to Deposit
____Percentage to Deposit
____Excess
$________________
%________________
Financial Institution Name:
Allocation Priority:             ___1                ___2                ___3                              
The order of deposit if you are depositing more than one account
Financial Institution Address:
Account Information:
Routing#:
Account#:
Type of Account:         ____Checking
____Savings
Check One:
____Full Deposit
____Amount to Deposit
____Percentage to Deposit
____Excess
$________________
%________________
AUTHORIZATION
I authorize _________________________(the "Company") and the financial institution indicated above to deposit my pay automatically to my 
account each payday.  If monies to which I am not entitled are depisted in my account, I authorize the Company to direct the financial 
institution to return said funds.  This authorization will remain in effect until i have cancelled it in writing in such a manner as to afford the 
Company and the financial institution a reasonable opportunity to act on it.
Employee Signature
Date_____________________        Location Phone#_________________
This form cannot be processed without proper documentation.

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