Direct Deposit Authorization Form printable pdf download

Direct Deposit Authorization Form

I authorize

to deposit my pay automatically to the account(s) indicated below and, if necessary, to

adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will

remain in effect until I cancel it in writing.

Please attach a voided check for each bank account to which funds should be deposited.

Print Full Name: ______________________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip: _______________________________________________________________________

Please enter the ABA bank routing and

account numbers for your checking account

as well as attach a voided check. See the

example to the left for where these numbers

are located on the lower portion of the

check sample.

CHECKING DEPOSIT

ABA Bank Routing # _______________________ Bank Account # __________________________

I wish to deposit to checking:

a flat amount of $_________.00

________% of my net pay

My entire net pay

SAVINGS DEPOSIT

ABA Bank Routing # _______________________ Bank Account # _________________________

I wish to deposit to savings:

a flat amount of $_________.00

________% of my net pay

My entire net pay

OTHER ACCOUNT

ABA Bank Routing # _______________________ Bank Account # _________________________

I wish to deposit to:

Checking

a flat amount of $_________.00

Savings

________% of my net pay

My entire net pay

NOTE: Savings and Credit Union accounts may use different ABA and/or Account Numbers for ACH transactions. It

is each employee’s responsibility to call their bank and acquire the correct information for initiating direct deposits into

such accounts.

I understand I am responsible for confirming that my pay has been properly deposited each payroll. No

transactions will be initiated against those funds until that confirmation has been made. Any Non-Sufficient

Funds charges that occur because I have failed to abide by this will be my responsibility.

Employee Signature: _________________________________________

Date: __________________

Direct Deposit Authorization Form