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
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