DIRECT DEPOSIT AUTHORIZATION

Fill in the boxes and sign the form.

Last Name *

First Name *

Middle Initial

Social Security Number *

Work Phone *

Action *

New Change Cancel

Effective Date *

Name of Financial Institution *

Account Number (includes hyphen, no spaces or special symbols) *

Type of Account *

Checking Savings

Routing Transit Number (must be 9 characters; first two digits 01–12 or 21–32) *

Type of Ownership *

Solo Joint Other

HOW TO COMPLETE THIS FORM

Fill all the necessary data in the fields above.
Sign and date the form.

TIP: Call your financial institution to make sure that they will accept direct deposit.

TIP: Verify your account number and routing transit number with your financial institution.

TIP: Do not use a deposit slip to verify the routing number.

By signing this agreement I authorize the agency to initiate credit entries to the account indicated above for the purpose of expense and/or payroll. I also authorize the agency to initiate, if necessary, debit entries and adjustments for any credit entries made in error.

Signature *

Date (Signature) *

If the account is a joint account or in someone else's name, that individual must also agree to the terms stated above before signing below.

Joint Account Signature (if applicable)

Date (Joint Signature)

Test

Test

DIRECT DEPOSIT AUTHORIZATION

HOW TO COMPLETE THIS FORM