Fillable Printable Direct Deposit Form - Arizona

Direct Deposit Form - Arizona

Direct Deposit Form

Please complete the form online then print, sign, fax or mail

to the Originator's Payroll/Accounting Dept.

Direct Deposit Form

Routing Number 322172742

Personal (Receiver/

Member)

(Originator Name/ Employer)

Last Name

Suffix

None

Last Name

Suffix

None

First Name MI First Name MI

Social Security #

Address City Employer Address City

State

Arizona

ZIP

State

Arizona

ZIP

Home Phone Employer Contact Person

E-mail Address Phone Number

Work Phone

Account Number

Ex: 12345-6 = 0000123456

Employer's Address City

State

Arizona

ZIP

Deposit/Net Amount

Choose one

Signature

Choose one of the following:

Start Change Cancel

I hereby authorize the above Originator to deducted from salaries, wages, or other dues in the amount

specified above which are for remittance to First Credit Union, 25 S. Arizona Place, Suite 111, Chandler, AZ

85224, for credit to my account.

___________________________________________________

Signature

____________________

Date