Direct deposit authorization form

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

I hereby authorize my employer to directly deposit my pay in the bank account listed below. (If two accounts are designated, deposits are to be made in whole percentages of pay to total 100 percent.) I am attaching a voided check or a deposit slip for the account specified below. This authorization is to remain in force until the company has received written authorization from me of its termination or change.

Also, I grant [name of organization] the right to correct any Electronic Funds Transfer resulting from an erroneous overpayment by debiting my account to the extent of such overpayment.

Employee Information:

Name:

Address:

Phone Number:

Department:

Extension:

Signature:

[organization use only] Effective date:

Financial institution information-Account No. 1:

• Checking

• Savings

[Check only one above]

Name of Financial Institution:

Address:

City, State, Zip Code:

Phone Number:

Personal Account Number: [please verify the complete number with your bank]

Percent of pay to be deposited in this account: %

[For Organization Use Only]

Employee Number:

Payroll Number:

Bank/ABA Number-Account 1:

Financial institution information-Account No. 2:

• Checking

• Savings

[Check only one above]

Name of Financial Institution:

Address:

City, State, Zip Code:

Phone Number:

Personal Account Number: [please verify the complete number with your bank]

Percent of pay to be deposited in this account: %

[For Organization Use Only]

Employee Number:

Payroll Number:

Bank/ABA Number-Account 2:

<p>Direct Deposit Enrollment Form. The following is a sample Direct Deposit Enrollment Form that allows employees to sign up for direct pay deposit.</p>

Direct deposit authorization form

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