Fillable DIRECT DEPOSIT AUTHORIZATION FORM

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DIRECT DEPOSIT AUTHORIZATION FORM

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DIRECT DEPOSIT AUTHORIZATION FORM
This form MUST be filled out COMPLETELY
Allow 2 pay cycles for Direct Deposit to Pre-note. You will receive a live check for the first 2 pay cycles.
Name of Employer:
Employee Name: Social Security #:
Account 1
Type of Account
Checking (attach voided check)
Savings (attach savings slip)
Amount to Deposit
Total Net Pay
Dollar Amount
% of check: %
Add to Direct Deposit
Terminate from Direct Deposit
Bank Name:
Bank Routing #
Bank Account #
City & State:
Account 2
Type of Account
Checking (attach voided check)
Savings (attach savings slip)
Amount to Deposit
Total Net Pay
Dollar Amount
% of check: %
Add to Direct Deposit
Terminate from Direct Deposit
Bank Name:
Bank Routing #
Bank Account #
City & State:
I authorize my employer/payer to initiate electronic credit entries and, if necessary, debit entries and adjustments for
any credit entries made in error, to my financial institution listed above. I am aware that it is my responsibility to
verify that funds are deposited prior to writing checks or debiting account.
Employee Signature Date
************************************************************************************************************************************************************************
Attach a voided check (not a deposit slip) from your checking account here to validate account information..
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DIRECT DEPOSIT AUTHORIZATION FORM

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Completed 2 March 2021

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