Expense Reimbursement Direct Deposit Enrollment Form printable pdf download

Expense Reimbursement Direct Deposit Enrollment Form

Expense Reimbursement Direct Deposit

Enrollment Form

To enroll in Expense Reimbursement Direct Deposit, simply fill out this form and return it to the

Accounting Department. Attached a voided check for each checking account-not a deposit slip. If

depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account.

It isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid

correctly.

Below is a sample check detailing where the information necessary to complete this form can be found.

Important! Please read and sign before completing and submitting.

I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating

credit entries to my accounts at the financial institutions (hereinafter “Bank”) indicated on both sides of

this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to

my accounts. In the event that Company deposits funds erroneously into my account, I authorize

Company to debit my account for an amount not to exceed to original amount of erroneous credit.

This authorization is to remain to full force and effect until Company and Bank have received written

notice from me of its termination in such time and in such manner as to afford Company and Bank

reasonable opportunity to act on it.

Employee Name:

Social Security #:

Employee Signature:

Date:

Account Information

Bank Name/City/State:

Routing/Transit #:

Account Number:

Checking

Savings

Expense Reimbursement Direct Deposit Enrollment Form