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: