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Direct Deposit Form

This document is a direct deposit authorization form for an employee of Albert Einstein College of Medicine. It provides fields for the employee to fill in their personal information and banking details to set up direct deposit for their payroll payments. The employee authorizes their employer to deposit their net salary into up to three bank accounts, and agrees to notify the employer in writing if they want to terminate direct deposit. Payroll will input the account information but the next payment will be by physical check during verification of the new banking information.

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lordperson
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404 views1 page

Direct Deposit Form

This document is a direct deposit authorization form for an employee of Albert Einstein College of Medicine. It provides fields for the employee to fill in their personal information and banking details to set up direct deposit for their payroll payments. The employee authorizes their employer to deposit their net salary into up to three bank accounts, and agrees to notify the employer in writing if they want to terminate direct deposit. Payroll will input the account information but the next payment will be by physical check during verification of the new banking information.

Uploaded by

lordperson
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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HRIS Payroll Services

Direct Deposit Authorization Form

Last Name: ___________________________ First Name: _________________________ M._____

Banner ID:___________________ Phone Number:_________________________


I authorize my employer, Albert Einstein College of Medicine, Inc, to deposit my net salary into the account(s)
indicated below.

To ensure that my account(s) is/are properly credited, I have attached a voided check from the checking
account(s), or a deposit slip from the savings account(s) where I have requested my net salary to be
deposited.

I agree that this authorization will remain in effect until I provide written notification to Albert Einstein
College of Medicine, Inc terminating this service.

Please indicate your payroll frequency: ( ) Semi-monthly ( ) Bi-Weekly

___________________________________ __________________
Signature Date

You may list up to three accounts below, including the Credit Union

Bank Name: Bank Name: Bank Name:

____________________ ____________________ ____________________

Bank address:________ Bank address:________ Bank address:________

____________________ ____________________ ____________________

Title of Account: Title of Account: Title of Account:

____________________ ____________________ ____________________

O Checking O Saving Acct O Checking O Saving Acct O Checking O Saving Acct

Bank Routing Number: Bank Routing Number: Bank Routing Number:

____________________ ____________________ ____________________

Bank Account Number: Bank Account Number: Bank Account Number:

____________________ ____________________ ____________________

____% to be deposited _____% to be deposited _____% to be deposited

Percentages must add up to 100%

Please note: You will receive your next payment in the


For Payroll use only: form of a physical check by mail while your new account
Input by (Init):______ Date:______ information goes through a verification process.

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