Employee Direct Deposit Authorization Agreement Template

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EMPLOYEE DIRECT DEPOSIT AUTHORIZATION AGREEMENT
(Please Complete One Form For Each Deposit Request)
Company #:
Company Name:
I (we) hereby authorize and request the COMPANY, to make payment of any amounts owing to me (either of us) by initiating credit
entries to my (our) account indicated below in the bank named below, hereinafter called BANK, and I (we) authorize and request BANK
to accept any credit entries initiated by COMPANY to such account and to credit the same to such account without responsibility for the
correctness thereof.
I (we) authorize and request COMPANY to effect repayment to COMPANY for amounts owed it because of a prior erroneous credit
initiated to my (our) account if prior to the correcting entry, the COMPANY has sent or delivered to me written notice of the correction
and the reason therefore; and the correcting entry is transmitted in such time as to be delivered or made available to BANK before
midnight of the tenth day next following settlement for the erroneous entry.
It is understood that this agreement may be terminated by me (either of us) at any time by written notification to COMPANY or BANK.
Any such notification to COMPANY shall be effective only with respect to entries initiated by COMPANY after receipt of such notification
and a reasonable opportunity to act on it. Any such notification to BANK shall be effective only with respect to entries credited to my
(our) account by BANK after receipt of such notification and a reasonable time to act on it.
I (we) recognize, acknowledge and accept this service is being provided for my (our) convenience. As such, I (we) agree to hold the
COMPANY, PayData Payroll Services, Inc., each participating bank and NACHA harmless from any claim incident to the operation of
this plan, arising from any act or omission by the COMPANY and/or PayData Payroll Services, Inc. and their employees, including
without limitation any claim based on alleged loss as a result of non-credit of any deposit, and any claim which may be made by any
depositor as a result of the rejection of any of his/her debits because of insufficient funds arising from the failure to credit deposits to
his/her account.
ATTACH VOIDED CHECK AS PROOF OF ACCOUNT NUMBER AND ROUTING TRANSIT NUMBER
PRE-NOTE: PayData highly encourages that all account go through the pre-noting process. The ONLY times when you
should say Pre-note NO is if you are setting up a Direct Deposit account that will be used with an HSA.
Employee #: _____________________ Name of Institution: _________________________________________
Routing #: ___________________________
Account #: __________________________________________
Account Type:
Deposit Options: (Select Only One)
________ Checking
________ Savings
________Deposit ENTIRE Net Pay Amount
________Deposit $ __________ of Net Pay Each Pay Period
________ Checking (HSA)
________Deposit
__________ % of Net Pay Each Pay Period
Single HSA
2 Person/Family HSA
Cancel Direct Deposit
Employee Name: __________________________________________________________
(Please Print)
Employee Signature: _____________________________________
Date: ______________
Co-Owners Name: _________________________________________________________
(Please Print)
Co-Owners Signature: ____________________________________
Date: ______________
Please complete one form for each deposit request
PayData strongly encourages that the employee keep a copy of this document for their personal records. The Employer should keep the
original. A copy of this form and a ‘voided’ check should be forwarded to PayData for set up. Upon set up completion, verification of the data
entered should be reviewed and any errors reported to PayData within 10 business days.

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