Employee Name: _________________________
Emplo
yee ID: ____________________________
Effective Date: ______________
Phone: ___________________
BANK INFORMATION
Deposit Priority (2) Deducts this amount 2nd
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing# (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________ Checking Savings
Deposit Priority (3) – Deducts this amount 3rd
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________
Checking Savings
Deposit Priority (4) – Deducts this amount 4th
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ______________________
Bank Name: ___________________________________ Checking Savings
Deposit Priority (5) – Deducts this amount 5th
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ _____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ____________________
Bank Name: ___________________________________ Checking Savings
I herby authorize the City of Brockton to deposit my net pay as indicated above at the financial institution(s) named above. I understand and agree
to hold the above named financial institution(s) harmless for any erroneous deposits or adjustments not caused by the financial institution.
It is understood that I may terminate this agreement at any time by written notification to the Human Resources Department. Any such notification
to the City shall be effective only with respect to entries initiated by the City after receipt of such notification and reasonable opportunity to act
upon it.
EMPLOYEE SIGNATURE: ____________________________________________ DATE: ______________________
CITY OF BROCKTON
Deposit Priority (1) – Deducts this amount 1st
Allow Partial Deduction
Full Deposit or Balance
Bank Transit/Routing# (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________ Checking Savings
New Delete
Change New Amount $ ____________
AUTHORIZATION AGREEMENT FOR EMPLOYEE DIRECT PAYROLL DEPOSIT
Please note: Regarding "Full Deposit or Balance" - Only One Box can be checked
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