Fillable Direct Deposit Enrollment Form PDF (City of Fitchburg)

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Direct Deposit Enrollment Form PDF (City of Fitchburg)

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The Direct Deposit Enrollment Form PDF (City of Fitchburg) form is 1 page long and contains:

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  • 2 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Fitchburg

BROWSE CITY OF FITCHBURG (MA) FORMS

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City of Fitchburg
166 Boulder
Drive Suite 108
Fitchburg, Massachusetts 01420
Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize the City of Fitchburg to initiate automatic deposits to my account at the financial institution
named below. I also authorize the City of Fitchburg to make withdrawals from this account in the event you
were overpaid incorrectly.
Further, I agree not to hold the City of Fitchburg 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 the City of Fitchburg receives a written notice of cancellation from me
or my financial institution for just cause, or until I submit a new direct deposit form to the Payroll Department. Any
such information shall be effective only with respect to entries initiated by the City of Fitchburg after receipt of
such notification and a reasonable opportunity to act. ANY SUCH NOTIFICATION TO THE FINANCIAL
INSTITUTION BY THE EMPLOYEE IS UNACCEPTABLE.
Account Information
Name of Financial Institution:
Address of Financial
Institution:
Routing Number:
Account Number:
Checking
Savings
Signature
Employee Name: (please print)
Employee
Authorized Signature:
Date:
Please attach a voided check and return this form to the Payroll
Department.
11.20.12 sn
Municipal Offices
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Direct Deposit Enrollment Form PDF (City of Fitchburg)

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Completed 15 July 2020

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