Direct Deposit Authorization

Authorization Statement:

By signing the Direct Deposit Authorization form below, you are agreeing to the following:

* I authorize my employer and the bank listed above to deposit my net pay or a portion thereof as indicated into my account each pay date.

*If funds to which I am not entitled are deposited to my account, I authorize my employer to direct the bank to return said funds to my employer.

*I understand that my deposit may not be credited to my account until midnight on the pay date indicated on the check voucher.

*I understand that it is my responsibility to ensure that my wages are being deposited correctly into my account each pay date.

*I understand that each new account will go through a pre-notification process that may take two payroll periods to complete.

THE BELOW NUMBERS MUST BE VERIFIED BY YOUR BANK AS BEING THE CORRECT TRANSIT/ABA AND ACCOUNT NUMBERS FOR ACH DIRECT DEPOSIT. WARNING: CREDIT UNIONS AND SOME OTHER BANKS OFTEN REQUIRE A DIFFERENT NUMBER(S) THAN THE NUMBER(S) ON YOUR CHECKS – THERE IS $10.00 CHARGE TO CORRECT AN INCORRECT NUMBER – PLEASE VERIFY WITH YOUR BANK OR CREDIT UNION.

Employee Name:

Last 4 Digits of SSN:

Date

Employer:

Account Number:

Transit Number:

Account:

Untitled

CHECKING ACCOUNT

SAVINGS ACCOUNT

Bank Name:

Branch:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DOLLAR AMOUNT TO BE DIR. DEPOSITED:

Employee Signature:

Date