Direct Deposit Authorization
Uploaded by
jenniferramage50Direct Deposit Authorization
Uploaded by
jenniferramage50Direct Deposit Authorization Form
(Mark selections with an “X”)
Name: Jennifer Ramage Goss
Street Address: 833 S. Vance St. B308
City, State, ZIP: Lakewood, CO 80226
X Start direct deposit
Change financial institution to Bellco
Change account information within Bellco
Change amount sent to Bellco
Bellco Routing/Transit Number: 302075018
X Checking Savings (check one)
Account Number:
Deposit all of my check
Deposit part of my check (specify amount per pay period): $
Bellco employee verification that information is accurate:
Name: Date:
IMPORTANT: If a Bellco representative has not signed the above verification, please attach a voided check.
Sign Below
I hereby authorize and request my employer to make payment of my earning by initiating credit or
adjustment entries to my account listed above. I also authorize and request Bellco to accept any such entried or
adjustments to my account without Bellco being responsible for the correctness thereof. If funds to which I am
not entitled are deposited to my account, I authorize my employer to direct Bellco to return said funds. Such
automatic deposits will be made on each successive payday unless I terminate this agreement. Cancellation of
direct deposit needs to be directed to my employer’s payroll department.