CITY OF LEBANON
DIRECT DEPOSIT AUTHORIZATION FORM
PLEASE PRINT CLEARLY
Employee Name: Employee #
Establishing direct deposit transactions (including changes) requires a ten (10) day notification
period before funds are deposited. During the notification period, a payroll CHECK
will be
generated.
•
If you are splitting the direct deposit, a set dollar amount must be designated to be deposited into one account with the
remaining deposit into the other.
•
For all accounts the following documentation
must be
submitted with this request:
Checking Account
- Voided check
Savings Account
- Proof of account name and number
ACCOUNT INFORMATION
Account Type: Checking Account Savings Account
Financial Institution Name and Address:
Financial Institution Transit or Routing # Account Number:
Type of Deposit: Full Net Pay Partial Deposit Amount: Remaining Net Pay
ACCOUNT INFORMATION
Account Type: Checking Account Savings Account
Financial Institution Name and Address:
Financial Institution Transit or Routing # Account Number:
Type of Deposit: Full Net Pay Partial Deposit Amount: Remaining Net Pay
ACCOUNT INFORMATION
Account Type: Checking Account Savings Account
Financial Institution Name and Address:
Financial Institution Transit or Routing # Account Number:
Type of Deposit: Full Net Pay Partial Deposit Amount: Remaining Net Pay
By signing this agreement, I hereby authorize and request the City of Lebanon to make payments owed to me for payroll by
initiating credit entries into my account(s) indicated above. I also authorize the City of Lebanon to initiate, if necessary, debit
entries and adjustments for any credit entries made in error. This authority will remain in effect until I have cancelled it in
writing.
Employee Signature: Date:
Establishing direct deposit transactions (including changes) requires a ten (10) day notification
period before funds will be deposited. During the notification period, a paycheck CHECK will be
generated. TWO SEPARATE BANKING INSTITUTIONS ONLY.
click to sign
signature
click to edit
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