Payroll Direct Deposit Authorization Form
(THIS FORM CHANGES ONLY AN EMPLOYEE BANK ACCOUNT(S) FOR DIRECT DEPOSIT)
I, ___________________________________, (employee) do hereby authorize
_______________________________________ (employer) to deposit my payroll check directly into all of my
Checking or Savings accounts as specified below or (if checked) add to my Payroll Debit Card. I understand
this authorization will remain in effect until I provide timely written notice to cancel this service. I also
understand that my account may receive a prenote ($0.00) transaction one pay cycle before I can begin the
direct deposit on a live basis. I authorize any overpayments to me to be electronically deducted from my
account or Payroll Debit Card.
Account(s) to be credited (can be deposited in multiple accounts):
Voided check (not a deposit slip) or a Savings account deposit slip must be attached to process request.
Bank No.___________________ Acct. # _____________________%, $ or Net __________
Type of account: Checking ____, Savings ____
Bank No.___________________ Acct. # _____________________%, $ or Net __________
Type of account: Checking ____ Savings ____
Bank No.___________________ Acct. # _____________________%, $ or Net __________
Type of account: Checking ____ Savings ____
______ I authorize my employer to add my Net Pay to the balance of my Payroll Debit Card.
(i.e.: 100% into checking; or $20.00 into Savings, Net amount into Checking; or 10.00% into Savings, Net
amount into Checking or Payroll Debit Card)
____________________________________
Signature of employee
_____________________________________
Date
Attach voided check here
