Direct Deposit Authorization Form

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Direct Deposit Authorization Form
I authorize
to deposit my pay automatically to the account(s) indicated below and, if necessary, to
adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will
remain in effect until I cancel it in writing.
Please attach a voided check for each bank account to which funds should be deposited.
Print Full Name: ______________________________________________________________________
Address: ____________________________________________________________________________
City, State, Zip: _______________________________________________________________________
Please enter the ABA bank routing and
account numbers for your checking account
as well as attach a voided check. See the
example to the left for where these numbers
are located on the lower portion of the
check sample.
CHECKING DEPOSIT
ABA Bank Routing # _______________________ Bank Account # __________________________
I wish to deposit to checking:
a flat amount of $_________.00
________% of my net pay
My entire net pay
SAVINGS DEPOSIT
ABA Bank Routing # _______________________ Bank Account # _________________________
I wish to deposit to savings:
a flat amount of $_________.00
________% of my net pay
My entire net pay
OTHER ACCOUNT
ABA Bank Routing # _______________________ Bank Account # _________________________
I wish to deposit to:
Checking
a flat amount of $_________.00
Savings
________% of my net pay
My entire net pay
NOTE: Savings and Credit Union accounts may use different ABA and/or Account Numbers for ACH transactions. It
is each employee’s responsibility to call their bank and acquire the correct information for initiating direct deposits into
such accounts.
I understand I am responsible for confirming that my pay has been properly deposited each payroll. No
transactions will be initiated against those funds until that confirmation has been made. Any Non-Sufficient
Funds charges that occur because I have failed to abide by this will be my responsibility.
Employee Signature: _________________________________________
Date: __________________

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