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Direct Deposits

This document is a non-federal direct deposit enrollment form. It provides instructions for completing the form, including ensuring it is fully filled out and signed. It also lists the required account information for direct deposit including the account type, deposit amount, account and routing numbers. The form authorizes the employer to make direct ACH deposits into the designated bank account.

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ken frost
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2K views1 page

Direct Deposits

This document is a non-federal direct deposit enrollment form. It provides instructions for completing the form, including ensuring it is fully filled out and signed. It also lists the required account information for direct deposit including the account type, deposit amount, account and routing numbers. The form authorizes the employer to make direct ACH deposits into the designated bank account.

Uploaded by

ken frost
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Non-Federal Direct Deposit Enrollment Request Form

Authorization agreement for automatic deposits (ACH)

Please follow these directions

1. Ensure the entire form is complete. If printing, sign and date it.

2. If providing this form directly to your Employer, they should review this form for completeness
and suitability. If Employer / Company prefers or requires their own form, use the account type,
number and ABA routing number below to complete their form.

3. Enter the account information on the form into your employers Human Resources Payroll portal
or provide it to your employer.

Employer or Company name: Goodwrx


Account type: MYAC
Deposit amount: 100%
Account Number: 501026620125
State where opened: NV
ABA routing number: 122400724

1001
KENDELL PIERCE
711 E NELSON AVE APT 3029
____________
NORTH LAS VEGAS, NV 89030-1817 Date
Pay To The
Order Of _____________________________________________________________________________ $ _____________________

VOID
_____________________________________________________________________________________ Dollars

For _____________________________________ ________________________________________________________

:122400724: 501026620125 1001

I (we) authorize the above named Employer / Company to initiate credit entries to my Bank of
America checking and / or Savings accounts indicated below and to credit the same to such
account. I (we) acknowledge that the origination of the ACH transaction to my (our) account must
comply with the provision of U.S. law.

Customer name: _______________________


Signature: _______________________
Date: _______________________

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