Direct Deposit Authorization

Direct Deposit Authorization Note Please complete this form and return it to the payroll department. Be sure to include a voided (Cancelled) check from your checking account and/or a deposit slip for your savings account, whichever is applicable. The details from the check / deposit slip will be used to verify the account details. You also have the option to deposit a part of your net pay into a secondary account, such as savings or credit union account. Please specify the dollar amount from your net pay that should be deposited in your secondary account. Name: Your Bank / Financial Institution: Social Security Number: City/State Primary Account Number Please check the applicable option: Checking Savings Pay Card Secondary Account Number Dollar Amount $ Please check the applicable option: Checking Savings I authorize and the above Financial Institution to deposit my net pay and/or flat amount automatically into my account(s) each payday, and to initiate any necessary adjustments for entries made in error to my account. (Signature) (Date) Attach Voided Check(s) / Deposit slip here. American LegalNet, Inc. www.FormsWorkFlow.com