Direct Deposit Authorization Form printable pdf download

Direct Deposit Authorization Form

Employee Instructions: Complete the Employee and Account information sections of this form.

For checking account deposits attach a voided check. For savings account attach an ABA

specification sheet from your financial institution with your account number. If you are a

returning employee and the bank information has NOT changed, mark the no change Box

and complete the Account Information, a voided check is NOT required.

Employee Information

Employee Name ____________________________________________________________

Social Security Number ___

_____________

Joint Account Holder's Name (if applicable)

Enrollment Action (select one)



New request

Change

Cancel

No Change to Bank Account

Mark what account you want your deposit to be deposited.

Checking Account: ____

Savings Account: ______

Account Information

Please complete the following information.

Institution Name/Branch Location _______________________________________________

□□□□□□□□□

Bank Routing/Transit Number

(The nine digits between these symbols

00000000000I:)

□□□□□□□□□□□□

Account Number

II)

(Account number is the digit following the Routing/Transit number and ending with

Direct Deposit Authorization: I understand the rules requiring my direct deposit request. I authorize

direct deposit of my payroll earnings into the account identified above. This authorization will remain

in effect until I have provided notice of a change in writing. Any type of account action requested will

take 4-6 weeks to be activated by employer.

Date

Employee Signature_ _________________________________________________________

For Payroll Use Only

Employee Number _________________________________________________________________

Date Received by Payroll Accountant __________________________________________________

Date Submitted to Express Pay _______________________________________________________

Direct Deposit Authorization Form