Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize LPTC and their payroll company to initiate automatic deposits to my account at the financial
institution named below. I also authorize LPTC and their payroll company to make withdrawals from this account in the
event that a credit entry is made in error.
Further, I agree not to hold LPTC and their payroll company responsible for any delay or loss of funds due to incorrect
or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial
institution in depositing funds to my account.
This agreement will remain in effect until LPTC and their payroll company receives a written notice of cancellation
from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
Account Information
ame of Financial Institution:
Routing Number:
Account Number: Checking | Savings
Amount to be Deposited Checking | Savings
ame of Financial Institution
Routing Number:
Account Number: Checking | Savings
Amount to be Deposited Checking | Savings
Signature
Authorized Signature (Primary): Date:
Authorized Signature (Joint): Date:
Please attach a voided check or deposit slip and return this form to the Payroll Department.
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signature
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click to sign
signature
click to edit
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