DIRECT DEPOSIT

AUTHORIZATION AGREEMENT

 

Replace with company name

Company Address

Phone Number

 

 

Type or Print

 

Employee Name

 

 Employee ID code

 

 

Bank Name

 

 

Bank Address

 

City

 

State

 

Zip

 

 

Bank Routing Number

 

 

 

 

 

 

**   Important Note:  The employee is responsible for contacting his/her bank or financial institution to confirm the bank routing numbers and account numbers.  The employee is also responsible for notifying Payroll immediately if the deposit bank changes or account numbers change.

 

**   Checking and Savings accounts do not need to be at the same bank.  A separate form is required for each bank.

 

Deposit to:

 

 

Checking Account Number

 

 

Payment Amount (Select One)

All / Balance of Pay  ___ (Check if Yes)

____ % of Pay

$_____ of Pay

 

Savings Account Number

 

 

Payment Amount (Select One)

All / Balance of Pay  ___ (Check if Yes)

____ % of Pay

$_____ of Pay

 

Other Account Number

 

 

Payment Amount (Select One)

All / Balance of Pay  ___ (Check if Yes)

____ % of Pay

$_____ of Pay

 

 

 

 

** EBMS does not limit the number of bank accounts that can be connected to direct deposit.

 

I hereby authorize Replace this text with your company name and the depository named above to initiate direct deposit (credit) entries and  correction (debit) entries to the depository account listed above.  This authorization will remain in effect until we as employer  receive written notification from you as employee at least 30 days prior to the effective date of the termination.

 

***PLEASE ATTACH A VOIDED PERSONALIZED CHECK TO THIS FORM FOR CHECKING ACCOUNT REQUEST.

 

 

 

Signature

 

Date

 

 

PAYROLL USE ONLY

 

Date entered______________________________________________________ Initials______________________________