Employee Direct Debit Authorization Form printable pdf download

Employee Direct Debit Authorization Form

EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM

I, [employee] ____________________________________, : hereby

authorize my employer, ___________________________ and its agents, including financial



institutions, to initiate electronic credit entries, and if necessary, debit entries and adjustments for

any credit entries in error to my checking and/or savings accounts listed below. This authorization

will remain in effect until I have informed my employer in writing that I wish to cancel it and my

employer has had reasonable time to effect such cancellation. I understand I should contact my bank

to verify receipt of funds

revise direct deposit bank account(s) as indicated below.



cancel direct deposit of my paycheck completely. This cancellation is to take effect immediately and



remain in full force and effect until the Company has received written notification from me of

authorization to deposit my paycheck automatically. I acknowledge that I will now receive

paychecks for which I am responsible for depositing and/or cashing.

Employee’s Signature: _________________________________ Date: _____ / ____ / ___________

Remaining Balance to 1

Account

Use Percentage

Pay

Acct.

Routing

Account

Bank Name/Address/Phone

Amount

Pct.

Order

Type

Number

Ckg

Sav

Ckg

Sav

Ckg

Sav

TOTAL: _____________

Please attach a voided check or deposit slip for each bank account to which funds will be deposited.

Example Routing Number: 123456789 Example Account Number: 022999999999

Employers: Keep for your records.

For additional information, see Instructions: Additional Forms > Direct Deposit Authorization

Employee Direct Debit Authorization Form