Fillable Printable Direct Deposit Authorization Form - Indiana University Health
Fillable Printable Direct Deposit Authorization Form - Indiana University Health
Direct Deposit Authorization Form - Indiana University Health
Indiana University Health Direct Deposit Authorization Form
Employee Name Employee Number
Social Security #
Employees can only have two (2) Direct Deposit Accounts, at any given time.
Primary Paycheck Direct Deposit
Initial Authorization No Change Change in Bank/Account Cancel/Stop
Name of Bank
Account # Checking OR Savings
Routing #
2nd (Additional) Paycheck Direct Deposit
Initial Authorization Change in Bank/Account Change in $ Amount Cancel/Stop
Name of Bank Amount of Deposit: $
Account # Checking OR Savings
Routing #
I hereby authorize IU Health:
•to deduct from my salary the amounts set forth above and
•to deposit these funds at the above financial institution(s) for each payroll period following receipt of
this authorization until further notice from me.
If this is a change in my previous authorization, I instruct IU Health:
•to cancel my previous authorization and
•to follow this authorization.
I also understand:
•This authorization may be changed only by my written request.
•This form will not be accepted unless I attach documentation of my account and routing numbers.
•Only computer generated or typed documentation may be used (Ex. Voided check or signature card).
PLEASE ATTACH YOUR ACCOUNT / ROUTING NUMBER DOCUMENTATION HERE.
Employee Signature: Date:
