Direct Deposit Authorization Form
DIRECT DEPOSIT AUTHORIZATION AGREEMENT
I hereby authorize the direct deposit of my net pay or payroll deduction by my employer in the account and financial institution indicated
below. I understand that such deposit will be made each succeeding payday, unless I choose to terminate this authorization in writing
to my employer. I also understand that notification to terminate or make changes to the directives below requires that a new Direct
Deposit Authorization form be completed and submitted to my employer and that the last fully completed form will stay in effect until
another is received.
Further, I agree not to hold my employer 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.
In the event that funds are erroneously deposited into my account, I further authorize my employer to debit my account for an amount
not to exceed the original amount of the credit, with the understanding that all debits will be made before the assigned pay-date.
Employee Signature: _________________________________________ Date:_______________________
DIRECT DEPOSIT ACTION REQUESTED (check only one)
□
Check Start if you don’t have direct deposit and wish to.
□
Check Change if you have direct deposit and wish to change from your financial institution to BrightStar CU or just wish to
change your account number or account type (Checking or Savings).
ACCOUNT INFORMATION
Employee Name
Name of Financial Institution:
BrightStar Credit Union
Transit Number:
267078299
Account Type
(check one)
Account Number (Enter below)
□Checking
□Savings
□□□□□□□□□□□□□
□□□□□□□□
□Net Pay or
□Specific Amount
$_________________
Per Pay Period
Employee Information
Employer and Location Location Number Employee Number Phone Number
For Payroll Use Only
Date
Received
Date
Processed
Processor
Transit Number Account Number
0 0 0 0
Please fill in the required fields online, before printing this Direct Deposit Form.
