Direct Deposit Authorization
Name:______________________________________________________________
Social Security Number:________________________________________________
Initial Authorization Change in
Authorization
I
hereby authorize my Employer to deduct from my salary the amounts set forth
below and to deposit these funds for each payroll period following receipt of
this Authorization until further notice from me. If this is a change in
previous Authorization, I instruct my Employer to cancel my Previous
Authorization and to follow this Authorization.
Please indicate the institution
and account where you would like your pay to be deposited. Up to Four (4)
accounts may be used. Indicate the percentage of your pay that you would like
in each account. To deposit your entire check, write 100 %. Deposits may be a
percentage of pay, or they can be a fixed dollar amount.
Institution:________________________ Account No.:(______________)________________________
Phone#____________________% or
$____________ Checking Savings
Institution:________________________ Account No.:(______________)________________________
Phone#____________________% or
$____________ Checking Savings
Institution:________________________ Account No.:(______________)________________________
Phone#____________________% or
$____________ Checking Savings
Institution:________________________ Account No.:(______________)________________________
Phone#____________________% or
$____________ Checking Savings
Please attach a voided check or
deposit slip for each account listed above. Direct Deposit will usually begin
within two pay periods of the date of authorization. Direct Deposit
Authorization Forms should be turned in to the Human Resources Department. On
pay weeks, Direct Deposit funds are available at
Signature:_____________________________________ Date:__________________________