Direct Deposit Form

This document is a Direct Deposit Authorization form that must be completed and returned to the payroll department. It requires a voided check or deposit slip for account verification and allows for a portion of net pay to be deposited into a secondary account. The form includes fields for personal information, account details, and authorization for automatic deposits.

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Direct Deposit Form

Uploaded by

bahnahj14

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Download as PDF, TXT or read online on Scribd

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Direct Deposit Authorization Note

 Please complete this form and return it to the payroll department.

 Be sure to include a voided (Cancelled) check from your checking account and/or a deposit slip for your savings
account, whichever is applicable. The details from the check / deposit slip will be used to verify the account
details.
 You also have the option to deposit a part of your net pay into a secondary account, such as savings or credit
union account. Please specify the dollar amount from your net pay that should be deposited in your secondary
account.

Name: Your Bank / Financial Institution:

Social Security Number: City/State

Primary Account Number Secondary Account Number

Dollar Amount $

Please check the applicable option: Please check the applicable option:

Checking □ Savings □ Pay Card □ Checking □ Savings □

I authorize _______________________________________________ and the above Financial Institution to

deposit my net pay and/or flat amount automatically into my account(s) each payday, and to initiate any
necessary adjustments for entries made in error to my account.

(Signature) (Date)

Attach Voided Check(s) / Deposit slip here.

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Direct Deposit Form

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Direct Deposit Form

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Direct Deposit Authorization Note

 Please complete this form and return it to the payroll department.

Name: Your Bank / Financial Institution:

Social Security Number: City/State

Primary Account Number Secondary Account Number

Checking □ Savings □ Pay Card □ Checking □ Savings □

I authorize _______________________________________________ and the above Financial Institution to

Attach Voided Check(s) / Deposit slip here.

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