Fillable Printable Payroll Direct Deposit Authorization Form Sample

Payroll Direct Deposit Authorization Form Sample

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