Onboarding Direct Deposit Enrollment Form
Restaurant Industry Leaders LLC
Company Name_____________________________________________________________________
Darinel Lopez
Employee/Worker Name______________________________________________________________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer.
EMPLOYERS: Please retain a copy of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of Routing/Transit Checking/Savings Financial Institution I wish to deposit (check one):
Account Number Account Number* (“Bank”) Name
✔ _____
100.00 % of Net
✔ Checking
Specific Dollar Amount $ ____
0 .00
Savings *0175 ******921 Citizens bank
Remainder of Net Pay
_____ % of Net
Checking
Specific Dollar Amount $ ____ .00
Savings Remainder of Net Pay
_____ % of Net
Checking
Specific Dollar Amount $ ____ .00
Savings Remainder of Net Pay
_____ % of Net
Checking
Specific Dollar Amount $ ____ .00
Savings Remainder of Net Pay
_____ % of Net
Checking
Specific Dollar Amount $ ____ .00
Savings Remainder of Net Pay
_____ % of Net
Checking
Specific Dollar Amount $ ____ .00
Savings Remainder of Net Pay
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit
transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am
either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits
into the named account.
05/15/24 11:51:40 292232735__118920779
05/15/2024
Employee/Worker Signature _________________________________ Date _____________
