DIRECT DEPOSIT AUTHORIZATION
TRIBAL MEMBER
NAME ________________________________________________________
LAST FOUR DIGITS OF SOCIAL SECURITY#_____________________________
NAME OF BANK_________________________________
ACCOUNT #_____________________________________
ROUTING #______________________________________
Please attach one of the following for Checking or Savings accounts (check one):
Voided check with name imprinted (no starter checks)
Bank letter or specification sheet (the signature of your local bank
representative MUST be included)
*Certain accounts may have restrictions on deposits and withdrawals. Check with
your bank for more information
specific to your account.
_____ % of Net
_____ Remainder of Net Pay
______Specific Dollar Amount $_______ .00
I authorize SANTA ROSA BAND OF CAHUILLA INDIANS to deposit my RSTF
payments into the bank accounts specified above. My signature below indicates that I
am agreeing that I am either the accountholder or have the authority of the
accountholder to authorize Santa Rosa Band of Cahuilla Indians to make direct
deposits into the named account.
Tribal Member Signature __________________________________________ Date ______________
Accountholder Signature ____________________________________
(if Tribal Member’s name does not appear on bank documentation)
