DIRECT DEPOSIT AUTHORIZATION FORM
Fill in the boxes below and sign the form.
Last Name First Name MI
Social Security Number Work Phone
Action Effective Date
Name of Financial Institution
Account Number Type of Account
Routing Transit Number Ownership of Account
By signing this agreement, I authorize ____________________ to initiate credit entries to the account indicated above for the purpose of expense and/or payroll.
I also authorize ______________________________ to initiate, if necessary, debit entries and adjustments for any credit entries made in error.
Signature____________________________________________________________________________________ Date ___________________
If the account is a joint account or in someone else's name, that individual must also agree to the terms stated above by signing below.
Signature____________________________________________________________________________________ Date ___________________
HOW TO COMPLETE THIS FORM
Month Day Year
New Change Cancel
(All 9 boxes must be filled. The first two numbers
must be 01 through 12 or 21 through 32.)
Self Joint Other
Checking Savings
(Include hyphens but omit spaces and special symbols.)
TIP
TIP
TIP
Call your financial institution to
make sure they will accept direct
deposits.
Verify your account number and
routing transit number with your
financial institution
Do not use a deposit slip to verify
the routing number.
250000005 1234556789022
JOHN PUBLIC
123 Main Street 19
Your Town, FL 12345
1234
PAY TO THE
ORDER OF
$
DOLLARSYour Town Bank
Your Town, FL 12345
For
Routing Transit Number
Account
Number
NOTE: THE ACCOUNT AND ROUTING NUMBER MAY APPEAR IN DIFFERENT PLACES ON YOUR CHECK.
1. Fill in all boxes above.
2. Sign and date the form.
E l e m e n t F C U
2 5 1 9 8 4 3 8 6
click to sign
signature
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signature
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