Direct Deposit Authorization Form
Please print and complete ALL the information below.
Name: ____________________________________________________________
Address: ____________________________________________________________
City, State, Zip: ____________________________________________________________
Name of Bank: ____________________________________________________________
Account #: ____________________________________________________________
9-Digit Routing #: ____________________________________________________________
Amount: $ ____________ ___________% or Entire Paycheck
Type of Account: Checking Savings (Check One)
Attach a voided check for each bank account to which funds should be deposited (if necessary)
_____________________ [Company Name] is hereby authorized to directly deposit my pay to
the account listed above. This authorization will remain in effect until I modify or cancel it in
Employee’s Signature: ______________________________________________________
Date: ___________________________
click to sign
click to edit