Non-Federal Direct Deposit Enrollment Request Form
Authorization agreement for automatic deposits (ACH credits)
Directions for Customer Use:
1) Ensure entire form is complete, then sign and date
Use the ABA routing number from the state where your account was opened
2) Ensure appropriate Employer / Company address is used when mailing completed form.
3) Employer/Company should review this form for completeness and suitability. If Employer /
Company prefers or requires their own form, use account type, number and ABA routing number below
to help complete their form
4) Mail form directly to Employer / Company (Note: It is not necessary for employer or company to return
the form to the bank once direct deposit is set up into the payroll system)
Employer / Company Name:
_____________________________________________________
Employer Address City State Zip
I (we) authorize the above named Company to initiate credit entries to my Bank of America Checking and/or
Savings accounts indicated below and to credit the same to such amount. I (we) acknowledge that the origination
of the ACH transactions to my (our) account must comply with the provisions of U.S. Law.
Note: Funds can be deposited into one account or split between accounts as a set percent or dollar amount.
Account type Checking Savings State Acct Opened
Account number
ABA Routing Number
Deposit Amount
% OR $
(Flat Amount) OR Remaining
Account type Checking Savings State Acct Opened
Account number
ABA Routing Number
Deposit Amount
% OR $
(Flat Amount) OR Remaining
Account type Checking Savings State Acct Opened
Account number
ABA Routing Number
Deposit Amount
% OR $
(Flat Amount) OR Remaining
If monies to which I am not entitled are deposited to my account, I authorize the Company (issuer) to direct the
financial institution to return said funds and I authorize the financial institution to act on the Company's direction
and to return said funds. This authority will remain in effect until Employer/Company has received written
notification from me of its termination in such time and in such manner as to afford Company and financial
institution a reasonable opportunity to act on it.
First Name Middle Name Last Name
Address City State Zip
- -
Signature (required) Date Tel Number
00-53-2276NSB 04-2010
NOTE: Written credit authorization must provide that the receiver may revoke the authorization only by notifying
the originator in the manner specified in the authorization.
Print
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