DIRECT DEPOSIT REQUEST FOR ACTION

EMPLOYEE NAME:

LOCATION

Please print name clearly using name as shown on your payroll check

LAST 4 DIGITS OF SSN:

Please check one of the following:

I authorize the automatic transfer of my net pay to the following bank account(s) indicated below.

Change my current bank accounts to the new bank acount(s) indicated below.

Add a secondary deposit(s) to the bank account indicated below.

Change my current secondary deposit(s) to the new amount indicated below.

Please delete my secondary account.

I no longer wish to participate in direct deposit.

Primary Account:(The balance of your net check after secondary deposit(s) are made.)

Bank Name

Phone:

Bank Routing/Transit Number

Bank Account Number

Circle One:

Checking

Savings

Secondary Account:

Bank Name

Phone:

Bank Routing/Transit Number

Bank Account Number

Circle One:

Checking

Savings

Deposit Amount:

Secondary Account:

Bank Name

Phone:

Bank Routing/Transit Number

Bank Account Number

Circle One:

Checking

Savings

Deposit Amount:

I understand that it is my responsibilty to verify the bank routing/transit number(s) and the bank account number(s) are accurate and active.

I understand that if incorrect information is given it will delay or prevent transfer of funds into my account(s).

I understand that I must notify the payroll department within 7 seven working days of the monthly paydate to make a change to my accounts or deposits.

Authorized Signature:

Date: