The Kroger Co. Delta Payroll Direct Deposit Authorization Form
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1The Kroger Co.
DELTA
Payroll Direct Deposit Authorization Form
Please complete the following to automatically deposit your pay into your bank account(s):
Name
Telephone Number/Extension
Division
Social Security Number
Work Location (City and State)
Paid:
Salary
Hourly
REMEMBER, THE TOTAL DISTRIBUTION MUST ADD UP TO YOUR TOTAL NET PAY.
When setting up your account(s), specify the exact dollar amount to be deposited in each account, but one account MUST
be coded "Net Pay". The amount deposited in this account will be the remainder after all other accounts are deducted.
1st BANK ACCOUNT:
Checking Account
OR
Savings Account
Start
Stop
Change
KEMBA
BANK NAME:
284 084 554
ROUTING #:
ACCOUNT #:
Net Pay
OR
Amount:________________
2nd BANK ACCOUNT:
Checking Account
OR
Savings Account
Start
Stop
Change
BANK NAME:
ROUTING #:
ACCOUNT #:
Net Pay
OR
Amount:________________
PLEASE ATTACH A VOIDED CHECK FOR THE ACCOUNT(S) ABOVE.
ATTACH VOIDED CHECK HERE
I AUTHORIZE MY EMPLOYER IDENTIFIED ABOVE (THE "COMPANY") TO DEPOSIT MY NET PAY AUTOMATICALLY EACH PAYDAY
INTO MY ACCOUNT(S) IN THE BANK(S) DESIGNATED ABOVE. IF ANY ERRORS ARE MADE BY MY BANK(S), I WILL NOT HOLD THE
COMPANY LIABLE. IF MONIES TO WHICH I AM NOT ENTITLED ARE DEPOSITED IN MY ACCOUNT(S) BY THE COMPANY, I AUTHORIZE
THE COMPANY TO DIRECT THE BANK(S) OR OTHER FINANCIAL INSTITUTION(S) TO RETURN THESE FUNDS.
THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL SUCH TIME AS MY EMPLOYMENT IS TERMINATED OR UNTIL SUCH CHANGE
OR CANCELLATION OF MY PAYROLL DIRECT DEPOSIT IS MADE IN WRITING BY ME AND IS RECEIVED BY THE PAYROLL DEPARTMENT.
EMPLOYEE'S SIGNATURE
DATE
Return To:
Interoffice Mail:
Fax:(620)560-6870
US Mail:
Kroger Acctg Svcs Hutchinson
KASH
Payroll - Delta
Payroll
P.O. Box 1648
Hutchinson, KS 67501
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Parent category: Business