City of Little Rock
Direct Deposit Agreement
Employee Name_________________________________________Employee ID# _________________
Social Security Number______________________
Financial Institution(s)
Primary
Are you replacing an existing account? Yes No
Bank or Credit Union Name______________________________Routing Number__________________
Account Number_______________________________________Checking Savings
Secondary Are you replacing an existing account? Yes No
Are you changing amount only? Yes No
Bank or Credit Union Name______________________________Routing Number__________________
Account Number_______________________________________Checking Savings
Dollar Amount:_____________________
PLEASE ATTACH A PRE-PRINTED VOIDED CHECK OR AN OFFICIAL FORM FROM THE
FINANCIAL INSTITUTION, CONTAINING THE REQUIRED INFORMATION. ANY FORMS
RECEIVED BY PAYROLL WITHOUT THE PROPER BACKUP WILL BE RETURNED.
‘A DEPOSIT SLIP WILL NOT BE ACCEPTED’.
Authorization
I hereby authorize the City of Little Rock to initiate direct deposit credit entries to my checking/savings account indicated above
and the Financial Institution above to post the same to such account.
I understand that signing up for primary direct deposit, all payments issued to me by the City of Little Rock will post to my
primary account.
This authorization is to remain in force until the City of Little Rock receives notice of cancellation from me. The notice of
cancellation must be received at least 30 days prior to cancellation and in such a manner as to afford the City of Little Rock
reasonable opportunity to act on it and in no event shall it be effective with respect to entries processed by the City of Little Rock
prior to receipt of the notice of cancellation. (Note: The City and the bank may cancel the agreement for direct deposit upon ten
days notice. If such a cancellation occurs, then direct deposit to the employee’s account will terminate despite the provisions of
this agreement.)
I further authorize the City of Little Rock to initiate such debit entries to said account as may be necessary to correct any
erroneous credit entries previously initiated thereto and I authorize the Financial Institution to accept and to credit or debit the
amount of such entries.
All entries initiated hereunder are to be governed in all aspects by the rules of the Mid-America Payment Exchange as now or
hereafter in effect.
Signed____________________________________________Date_______________________________
CANCELLATION ONLY
I hereby cancel the authorization for the City of Little Rock to originate direct deposit entries to my
checking/savings account indicated above, effective on _______________.
Signed ______________________________________________
08/29/11
