Fillable Printable Employee Direct Deposit Authorization Form - Virginia
Fillable Printable Employee Direct Deposit Authorization Form - Virginia
Employee Direct Deposit Authorization Form - Virginia
EMPLOYEE DIRECT DEPOSITAUTHORIZATIONAgencyName:
Print Employee Full N ame : _________ Employee ID #: _ _ _ _ _ _ _ _ _
I wish to have my employerdeposit my net paya nd/or trav el reimb urs eme nts and/or a fixed amount(s) each payday directly to my
account(s ) as indicated. I agree to notify my em ployer immediately of any changes to the information so that my pay may be properly
distributed. I understand that in the event my employer notifies my financial institution that I am not entitled to the funds deposited to my
account, my bank is authorized to debit my account for the amount of the adjustment.I understand that in the event my financial
institution is not abl e to deposit any electronic transfer into my account due to any action I take; that I am responsible for any resulting
bank fees incurred,and that my employer can not is sue the payroll funds to me until the funds are returned to my employer by my
financial institution.
As required by the Federal Office of Foreign Asset Control in support of U.S.C. Title 50, War and National Defense, I attest that the full
amount of m y direct deposit is not being forwarded to a bank in another country and that if at any point I establi s h a standing order for
my receiving bank to forward the full direct deposit to a bank in another country, I will inform my employing agency immediately.
Please note that, due to timing differences, new or changed direct deposits may result in one paper check after this form has
been submitted. Please do notclose your account(s) without giving your payroll office two weeks prior notice.
EmployeeSignatureDate
CHECKING ACCOUNTS. Attach a voided che ck for each account.If a voided check is not attached, this section
should be completed by your financ ial ins ti tut ion’srepresentat iv e inclu di ngname and signature in the sectionbelow**.
NET Direct Dep o sit to thefollowing CHECKING account:
New
_________________________ ______________________ ______________________ ___NET_______
Change
Name of Financial Institution Routing Number Checki ng Account Number Amount
Stop
FIXED Amount to the following CHECKING account(s):
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Routing Number Checking Account Number Amount
Stop
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Rou ting Number Checki ng Account NumberAmount
Stop
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Rou ting Number Checki ng Account Number Amount Stop
**Print nameof Financial Representative: ____________________________________ Phone: _______________
**Signature of Financial Representative: ____________________________________ Date: _______________
S AVINGS ACCOUNTS. Deposit slips can NOT be used.This section and the routing and account numbers below
should be completed by your financial institution’s representative including name and signature in the section above**.
NET Direct Deposit to the following SAVINGS account:
New
_________________________ ______________________ ______________________ ___NET_______
Change
Name of Financial Institution Rou ting Number Savings Account NumberAmount
Stop
FIXED Amount to the following SAVINGS account(s):
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Routing Number SavingsAccount Number Amount
Stop
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Rou ting Number Savings Account NumberAmount
Stop
New
_________________________ ______________________ ______________________ ____________
Change
Name of Financial Institution Rou ting Number Savings Account NumberAmount Stop
To be completed by the Agency Payro ll Section:
Checkingde duc t ion numbe r s : fi xe d15 9, 16 3, 167 Net checking 169Savings deduction numbers: fixed 160, 164, 168 Net s a vings 170
CIPPS Upda te d by:
___________Date ___/___/___ Reviewed by: ______________Date ___/___/___04/14
