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Direct Deposit
Complete this form and give it to your employer / payer.
If they prefer to use their own form, you can use this as a reference.
Deposit Account #1 Bank Name:
Account Number:
Routing Number:
Account Type: Checking Savings
Deposit Amount:
(Percentage or dollar amount)
Deposit Account #2 Bank Name:
Account Number:
Routing Number:
Account Type:
Checking Savings
Deposit Amount:
(Percentage or dollar amount)
Deposit Account #3 Bank Name:
Account Number:
Routing Number:
Account Type: Checking Savings
Deposit Amount:
(Percentage or dollar amount)
I authorize (company name) to initiate deposits and, if necessary,
withdrawals to correct erroneous deposit entries to my account(s) listed above. I understand that this
authorization replaces any previous authorization, and will remain in eect until the company named
above has received written notification from me of its termination in a reasonable enough time to act.
Name:
Signature:
Date:
George Abbott
VP, Consumer Banking
© 2018 Capital One. Capital One is a federally registered service mark. All rights reserved. Capital One and Capital One's family
of companies, including Capital One Bank (USA), N.A., and Capital One, N.A., Members FDIC.
Capital One
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signature
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