Approved/Updated 2/17/16
Direct Deposit Signup/Change Form
Name____________________________ Last Four #’s of Social Security _ _ _ _
Phone number_____________________
New Account Changing Existing Acct Info
COMPLETE TO ENROLL OR CHANGE ENROLMENT IN DIRECT DEPOST- PLEASE PRINT IN BLACK INK ONLY
Bank Account
Number*
Type of
Account
Financial Institution
(“Bank”) Name/City/State
Deposit Type
(check one):
Change my Deposit
Amount to:
Account #
________________
Ro
uting #
________________
Checking
Savings
Remainder of Net
Pay
_____% of Net
Specific Dollar
Amount $______.00
oRemainder of Net Pay
o_____% of Net
oSpecific Dollar
Amount $_____.00
oRemove from Direct
Deposit
Account #
________________
Ro
uting #
________________
Checking
Savings
Remainder of Net
Pay
_____% of Net
Specific Dollar
Amount $______.00
Remainder of Net Pay
_____% of Net
Specific Dollar
Amount $_____.00
Remove from Direct
Deposit
Please attach one of the following for Checking or Savings accounts (check one):
Voided check with name imprinted (no starter checks)
Bank letter or specification sheet (the signature of your local bank representative MUST be included)
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information
specific to your account.
WORKER CONFIRMATION STATEMENT
PLEASE PRINT IN BLACK INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above. My signature below indicates
that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer
to make direct deposits into the named account.
Worker Signature______________________________________ Date _________________________
Accountholder Signature________________________________
(If worker’s name does not appear on bank documentation)
NOTE: Digital or Electronic Signatures are not acceptable.
IMPORTANT: If your account becomes closed, please notify Tribal Admin/Payroll immediately. Not
doing so will cause delays receiving your per capita.
IMPORTANT: Completed form must be received by the 15
th
of the month.
click to sign
signature
click to edit