Employee Direct Deposit Enrollment Form

Employee Direct Deposit Enrollment Form

To enroll in Full Service Direct Deposit, simply fill out this form and give to your payroll manager. Attach a voided check for each checking account - not a deposit

slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number on a savings

deposit slip. This will help ensure that you are paid correctly.

Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.

Memo__________________________

|: 012345678|: 123456789” 0101

Routing/Transit #

Check #

Checking Account #

(A 9-digit number always between

(this number matches the number

in the upper right corner of the

these two marks)

check – not needed for sign-up)

IMPORTANT! Please read and sign before completing and submitting.

I hereby authorize _________________________________ (hereinafter “Employer”) to deposit any amounts owed me by initiating credit entries to my account at the

financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated to my account. In the event

that funds are deposited erroneously into my account, I authorize Employer to debit my account for an amount not to exceed the original amount of the erroneous credit.

This authorization is to remain in full force and effect until Employer and Bank have received written notice from me of its termination in such time and in such manner

as to afford Employer and Bank reasonable opportunity to act on it.

Employee Name: __________________________________________________

Employee Signature:

Date:

Account Information

The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form.

Make sure to indicate what type of account, along with amount to be deposited, if less than your total net paycheck.

1. Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __

Account Number: _________________________________

Checking

Savings

I wish to deposit: $ _______.____ or Entire Net Amount

2.

Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __

Account Number: _________________________________

Checking

 Savings

I wish to deposit: $ _______.____ or Entire Net Amount

3.

Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __

Account Number: _________________________________

 Checking

 Savings

I wish to deposit: $ _______.____ or Entire Net Amount

If Employer utilizes voucher e-mailing, I further authorize Employer to send my Direct Deposit voucher to my personal e–mail address in

lieu of the standard paper voucher. My e-mail address is:

E-mail: _______________________________@___________________________________________________

ATTENTION PAYROLL MANAGER:

Employers must keep each original employee enrollment form on file as long as the employee is using direct deposit, and for two years thereafter.