Fillable INSTRUCTIONS BELOW READ CAREFULLY USE THIS FORM TO (City of Hampton)

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INSTRUCTIONS BELOW READ CAREFULLY USE THIS FORM TO (City of Hampton)

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USE THIS FORM TO AUTHORIZE OR MAKE CHANGES IN DIRECT DEPOSIT.
The City of Hampton uses direct deposit for payroll distribution and employee reimbursements.
1. Be sure to print your information clearly.
2. Include a voided check from your personal account, or submit your bank's paperwork.
3. Make sure you have included your correct Social Security Number and have signed this form.
Please enroll me in the City's direct deposit plan. The depository information and authorization is as
provided below.
CITY OF HAMPTON
ID NUMBER: 54-6001336
I hereby authorize the City of Hampton Finance Department to initiate credit entries to my account indicated below and
the financial institution named below to credit the same to such account.
CHECKING [ ] SAVINGS [ ]
FINANCIAL INSTITUTION: STATE:
ROUTING # ACCOUNT #
SAME ACCOUNT AS PAYROLL [ ] OR CHECKING [ ] SAVINGS [ ]
FINANCIAL INSTITUTION: STATE:
ROUTING # ACCOUNT #
This authority is to remain in full force and effect until the City has received written notification from me the
undersigned) of its termination in such time and in such manner as to afford the City reasonable opportunity
to act upon said request.
NAME: SSN:
SIGNED: DATE:
PLEASE PRINT
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (CREDITS)
ATTACH VOIDED CHECK HERE
DIRECT DEPOSIT FORM
BANK ACCOUNT FOR TRAVEL ADVANCES AND OTHER REIMBURSEMENTS (A/P):
BANK ACCOUNT FOR PAYROLL DEPOSITS:
PLEASE
READ
INSTRUCTIONS BELOW
CAREFULLY
______________
____
CONTACT NUMBER:
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INSTRUCTIONS BELOW READ CAREFULLY USE THIS FORM TO (City of Hampton)

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Completed 3 August 2020

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