Direct Deposit Enrollment Form - Affiliated Payroll Services printable pdf download

Direct Deposit Enrollment Form - Affiliated Payroll Services

DIRECT DEPOSIT

ENROLLMENT FORM

Employee Information

Employer Information

PLEASE PRINT

Employer Name:____________________________

Employee Name:_______________________________

Federal ID Number:__________________________

Social Security Number: _________________________

Complete for DIRECT DEPOSIT and attach a VOIDED check. Deposit Slips are not

accepted. Note: If depositing into a Savings Account ask your bank for for the Routing/

Transit Number as the number on the Savings Deposit slip may not be the same.

I authorize my employer to deposit my wages/salary to the following bank account(s).

Bank Account #1 - Checking / Savings (Circle one)

Entire Net Amount

Bank Name___________________________________________

______% of Net

Routing Number _______________________________________

Specific Dollar Amount $_______

Account Number_______________________________________

Attach Voided Check Here

_________________________________

____________

Employee Signature:

Date:

By authorizing above, I agree that I am either the accountholder or have the authority of the accountholder to authorize my

employer to make direct deposits into the named account(s) above. Further, I agree that if my employer deposits funds into my

account in error they have the authority to remove those funds via an electronic transaction.

For Office Use Only

Date Received: __________________ Date Prenoted: __________________ Date Accepted:__________________

Comments:________________________________________________________________________________________

Direct Deposit Enrollment Form - Affiliated Payroll Services