Electronic Funds Transfer Form
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1Electronic Funds Transfer Form
Electronic Funds Transfer Form
I authorize my Employer to directly deposit my paycheck in
mployer to directly deposit my paycheck into the bank account or accounts
ccounts listed below
and in the percentages as specified. Designated deposits
and in the percentages as specified. Designated deposits to more than one account shall be made in
more than one account shall be made in
whole percentages and equal 100%.
100%. A voided check or deposit slip has been attached to this form for
as been attached to this form for
each account that is listed below. This
each account that is listed below. This authorization is to remain in effect until the company receives
authorization is to remain in effect until the company receives
written authorization from me that it is terminated or
written authorization from me that it is terminated or changed. I also grant my Employer the right to
I also grant my Employer the right to
correct any Electronic Funds Transfer
correct any Electronic Funds Transfer overpayment and give the Employer the ability to
the Employer the ability to deduct any
excess funds from the accounts liste
accounts listed below that do not rightfully belong to me.
Name: ____________________________________________________________________
__________________________________________________________
__________________________________________________________
Address:___________________________
_____________________City:________________State:_____Zip:
Zip:________
Telephone: (______)_________________
_________
Employee Signature:________________
ure:____________________________
Date: _____/_____/_______
Date: _____/_____/_______
Account #1) Checking [___] or Savings [___]
Checking [___] or Savings [___]
Financial Institution: ___________________________________________________________
__________________________________________________
__________________________________________________
Address:_____________________________
_____________________________City:________________State:_____
_____Zip:________
Telephone: (______)__________________
one: (______)__________________
Percent of pay check to be deposited into Account #1):_____%
Percent of pay check to be deposited into Account #1):_____%
Bank Account # ________________________ ABA Routing #___________________________
Bank Account # ________________________ ABA Routing #___________________________
Bank Account # ________________________ ABA Routing #___________________________
Account #2) Checking [___] or Savings [___]
Checking [___] or Savings [___]
Financial Institution: __________________________________________________________
__________________________________________________
__________________________________________________
Address:_____________________________
_____________________________City:________________State:_____
_____Zip:_______
Telephone: (______)__________________
one: (______)__________________
Percent of pay check to be deposited into Account #
Percent of pay check to be deposited into Account #2):_____%
Bank Account # ________________________ ABA Routing #___________________________
Bank Account # ________________________ ABA Routing #___________________________
Bank Account # ________________________ ABA Routing #___________________________
Company Use Only:
Effective Date: Date: _____/_____/_______
Date: _____/_____/_______
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