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Direct Deposit Authorization
You can use your keyboard to ll out this form online, or you can print the form and complete it by hand.
Company or Employer:
Address:
City, State, Zip:
Phone Number:
Employee ID:
Notication of Direct Deposit Authorization Change
Effective immediately, please deposit the net amount of my check to my Fox Valley
Savings Bank account. I authorize (name of depositor)
to automatically deposit funds into the account below. This authorization shall remain in
place until I have submitted a new authorization, or until this authorization is changed or
revoked by me in writing.
Signature:
Name:
Address:
City, State, Zip:
Phone Number:
(if applicable)
Date:
Direct Deposit Checklist:
Payroll
Investments
Retirement Plans
Social Security
Use this form to authorize your employer, retirement and pension funds, or any other agency to deposit your
payment directly into your Fox Valley Savings Bank account. Use one form for each direct deposit.
Use this list to remember all
your direct deposits you need
to transfer. These are the most
common direct deposits.
Place an X next to your desired option.
Net amount to Fox Valley Savings Bank CHECKING
Net amount to Fox Valley Savings Bank SAVINGS
Account #
Routing #
Account #
Routing #
275970130
275970130
