_____ NEW TO DIRECT DEPOSIT PROGRAM
________ ADD/CHANGE/DLETE EXISTING DIRECT DEPOSITS
PAYROLL DIRECT DEPOSIT AUTHORIZATION
EMPLOYEE NAME: DEPARTMENT: PHONE:
ACTION: PRIORITY: BANK NAME & ROUTING
NUMBER:
(1,2,3)
ACCOUNT #
UP TO 17 DIGITS
DEPOSIT TYPE: ACCOUNT TYPE: REGULAR
CHECKS ONLY:
ADD
DELETE
CHANGE
BANK
9 DIGIT ROUTING #
AMOUNT $___________
PERCENT %_________
BALANCE
CHECKING
SAVINGS
___
ACTION: PRIORITY: BANK NAME & ROUTING
NUMBER:
(1,2,3)
ACCOUNT #
UP TO 17 DIGITS
DEPOSIT TYPE: ACCOUNT TYPE: REGULAR
CHECKS ONLY:
ADD
DELETE
CHANGE
BANK
9 DIGIT ROUTING #
AMOUNT $___________
PERCENT %_________
BALANCE
CHECKING
SAVINGS
___
ACTION: PRIORITY: BANK NAME & ROUTING
NUMBER:
(1,2,3)
ACCOUNT #
UP TO 17 DIGITS
DEPOSIT TYPE: ACCOUNT TYPE: REGULAR
CHECKS ONLY:
ADD
DELETE
CHANGE
BANK
9 DIGIT ROUTING #
AMOUNT $__________
PERCENT %__________
BALANCE
CHECKING
SAVINGS
___
If you have selected CHECKING ACCOUNT, please attach a voided check to this form.
***Adding a new direct deposit or changing account type, bank identification number or account number requires a prenote to be sent to the bank before the add or
change becomes effective. A prenote sends your account type, bank ID and account number to the bank to assure the accuracy of the numbers. Changes should be
effective in two weeks of submitting a change.
REMARKS:
I authorize the Department of Finance and my financial institutions indicated above to initiate electronic credit entries (direct deposit) of the amounts I designated and if necessary,
debit entries and adjustments for any credit entries made in error to my accounts as I indicated above. I understand that this authorization will cause any previously authorized
direct deposits to financial institutions to be discontinued.
EMPLOYEE SIGNATURE: DATE:
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