AUTHORIZATION FOR DIRECT DEPOSIT
I hereby authorize Orange County, Virginia to initiate credit entries to my account(s) with the Depository (Bank) shown below. To
change or discontinue direct deposit to one or more accounts a new form must be submitted to payroll ten (10) days prior to month
end. Any requests received after the deadline cannot be guaranteed for the current month payroll.
For savings accounts, please attach a deposit slip to this form For checking accounts, please attach a VOIDED check to this form
Name:
Dept:
SSN (Last 4 digits):
Current Date
Add Change Delete
Bank Name (1):
Account #:
Routing #:
Checking Savings
Add
Change
Delete
Bank Name (2):
Account #:
Routing #:
Checking Savings
Deposit Amount:
Deposit Amount:
Add
Change Delete
Bank Name (3):
Account #:
Routing #:
Checking Savings
CANCELLATION
I HEREBY AUTHORIZE THE COUNTY OF ORANGE TO CANCEL MY DIRECT DEPOSIT AUTHORIZATION AGREEMENT
PLEASE RETURN TO PAYROLL DEPT.
Entered by: Date:
Signature:
E-mail:
Put "entire" if you want your whole check deposited,
"remainder" if you want the amount after all other
deposits, or list a specific deposit amount.
Put "entire" if you want your whole check deposited,
"remainder" if you want the amount after all other
deposits, or list a specific deposit amount.
Put "entire" if you want your whole check deposited,
"remainder" if you want the amount after all other
deposits, or list a specific deposit amount.
Deposit Amount:
Signature:
Date Received in payroll__________________________
