Direct deposit authorization
Direct deposit authorization form
DIRECT DEPOSIT AUTHORIZATION
Name:
I.D.#
S.S.#
Bank Name and Branch:
Account Number:
Check appropriate box:
( ) Direct deposit.
The undersigned hereby requests and authorizes the entire amount of my paycheck
each pay period to be deposited directly into the bank account named above.
( ) Direct payroll deduction deposit.
The undersigned hereby requests and authorizes the sum of dollars ($ )
be deducted from my paycheck each pay period and to be deposited directly
into the bank account named above.
( ) I would like to cancel my deposit authorization.
The undersigned hereby cancels the authorization for direct deposit or payroll deduction
deposited previously submitted.
Employee Signature Date
Please attach a copy of deposit slip
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