Authorization Agreement for Direct Deposit
Employer Name Client Number Employee Name
All requests for direct deposit must include one of the following acceptable documentation options:
Voided Check (from the issuing bank) Online Banking screenshot (ACH Routing & Account numbers visible)
Bank Letter (on letterhead & signed) Deposit Slips (with ACH Routing number)
Employees must complete this form when a direct deposit is new or changing. Have more than 2 accounts? Simply complete additional
forms as needed, up to the maximum of 9 accounts. Prenote is required without acceptable documentation.
Account #1 System Setup Guide
*Prenote: Recommended! Sends a test file to
the bank to verify account is valid, the employee
will receive a live check until verified. This can
Status* (see System Setup Guide) Account Type take up to 3 payroll cycles.
*Active: Sends funds via direct deposit to the
account, without testing bank accuracy. We
ACH Routing Number Bank Name/Description (Optional) recommend using Prenote status for all new
direct deposit accounts.
Sequence: Remaining Net Pay Remaining Net: One direct deposit account for
the entire employee net pay or the last account
Account Number 1 Partial* to receive the remaining net pay after partial
direct deposits.
*1, 2, 3 [Partial]: Used for partial direct
deposits by order of importance. One being first,
Account #2 see below. Can be an Amount or Percentage.
Example: Partial 1 or Sequence 1 - $50.00 to
Savings & Sequence Remaining Net to Checking
Status* (see System Setup Guide) Account Type Reminder: This form is not complete without a
voided check, account screenshot, deposit slip,
and/or banking institution letter.
ACH Routing Number Bank Name/Description (Optional) Additional Notes:
Sequence: Remaining Net Pay
Account Number 2 Partial*
I hereby authorize and request the company (hereinafter referred to as Employer) named above to make payment of any amounts owed to me by initiating
credit entries to my account indicated above at the bank named above. I also authorize and request the bank to accept any credit entries initiated by my
Employer to such account and to credit the same to such account without responsibility for the correctness thereof. I further authorize and request my
Employer to effect repayment to my Employer for amounts owed to it because of prior erroneous credit(s) initiated to my account.
It is understood that this agreement may be terminated by me at any time by written notification to my Employer. Any such notification to my Employer shall
be effective only with respect to entries initiated by my Employer after receipt of such notification and a reasonable opportunity to act on it.
I recognize, acknowledge, and accept that this service is being provided for my convenience. As such, I agree to hold my Employer, Heartland Payroll
Solutions, each participating bank and National Automated Clearing House Association (NACHA) harmless from any claim incident to the operation of this
plan, arising from any act or omission by my Employer or Heartland Payroll Solutions, their employees, including without limitation, any claim based on
alleged loss as a result of any non-credit of any deposit, and any claim which may be made by any depositor as a result of the rejection of any debits because
of insufficient funds arising from the failure to credit deposits to his/her account.
Internal Use Only (initial)
Employee Signature Employee Print Name & Date Date:
Entered by:
Verified by: Date:
Client/Authorized Representative Client/Authorized Representative Print Name & Date
Rev. 05/25/2023 Page 1 of 1
