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Direct Deposit Form

This document is a Direct Deposit Form that must be completed and submitted to the payroll provider for setting up direct deposits to a Green Dot account. It requires the account holder's personal information, including name, social security number, and banking details, and specifies that the information must match what is on file with the employer. The form also includes authorization for electronic deposits and provides a hotline for questions.

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bilejeananoh
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390 views1 page

Direct Deposit Form

This document is a Direct Deposit Form that must be completed and submitted to the payroll provider for setting up direct deposits to a Green Dot account. It requires the account holder's personal information, including name, social security number, and banking details, and specifies that the information must match what is on file with the employer. The form also includes authorization for electronic deposits and provides a hotline for questions.

Uploaded by

bilejeananoh
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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1/10/25, 2:29 AM Direct Deposit Form

Fill out this form and submit it to your benefits or payroll provider.
Make sure the name and social security number on file with your employer or benefits provider matches what’s on your Green Dot account exactly.
Green Dot will not be able to deposit your payment if we are unable to match recipients.

ENTER THE AMOUNT YOU WANT TO DEPOSIT EACH PAY PERIOD.


SELECT ONE:
ENTIRE CHECK AMOUNT % PER CHECK % AMOUNT PER CHECK $

SIGN & SUBMIT THIS FORM TO YOUR PAYROLL OFFICE.

SIGNATURE / DATE

NOT TO BE COMPLETED - FOR PAYROLL/BENEFITS USE ONLY

ACCOUNT TYPE: CHECKING LAST 4 DIGITS OF CARD: 5630


Christopher Haynie
2486 13th Ave N
Apt 106
Saint Petersburg, FL 33713-5856

ROUTING #: 124-303-120 DIRECT DEPOSIT ACCOUNT #: 302-621-035-933

QUESTIONS? CALL OUR DIRECT DEPOSIT HOTLINE AT (866) 795-7974.


Important: Your routing and direct deposit numbers may not be used to pay bills or take money off your Card.
All transactions of this type will be declined.

Direct Deposit Authorization: I authorize my employer or payor to electronically deposit my payroll or benefits check to my Green Dot card, unless otherwise revoked. This form
and the bank routing number and direct deposit account number are for the purpose of initiating direct deposits to the associated Green Dot card. Direct deposit capability is
subject to payor’s support of this feature. Cardholder must check with payor to find out when the direct deposit of funds will start. Funds availability is subject to timing of payor’s
funding.

https://secure.greendot.com/greendot/getacardnow/directdeposit?langid=en-us 1/1

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