DIRECT DEPOSIT REQUEST FORM
Complete this form, then print it, sign it and take it to your employer’s payroll department to request direct deposit
of your paycheck.
Customer name
Address
City State ZIP code
Please have my paycheck automatically deposited into the following account:
Checking account number
Or
Savings/MIA/Money market account number
Your bank’s routing number
You can nd your account and routing numbers when you sign in to chase.com:
• Click on the last four digits of your account number that appear above your account information, or
• Select the “Account & routing number PDF” from the “Things you can do” menu.
I authorize ________________________________________________________________________________________________ (name of business)
and my bank to automatically deposit my paycheck into my account listed above (this includes my authorization to
correct entries made in error). This authorization will remain in eect until I give written notice to cancel it.
Customer signature Date
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