Employee Direct Deposit Authorization Form - Free Download
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Employee Direct Deposit Authorization Form
Employee Direct Deposit Authorization Form
EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM
I, [employee] ____________________________________, : hereby
 authorize my employer, ___________________________ and its agents, including financial
institutions, to initiate electronic credit entries, and if necessary, debit entries and adjustments for
any credit entries in error to my checking and/or savings accounts listed below. This authorization
will remain in effect until I have informed my employer in writing that I wish to cancel it and my
employer has had reasonable time to effect such cancellation. I understand I should contact my bank
to verify receipt of funds
 revise direct deposit bank account(s) as indicated below.
 cancel direct deposit of my paycheck completely. This cancellation is to take effect immediately and
remain in full force and effect until the Company has received written notification from me of
authorization to deposit my paycheck automatically. I acknowledge that I will now receive
paychecks for which I am responsible for depositing and/or cashing.
Employees Signature: _________________________________ Date: _____ / ____ / ___________
Remaining Balance to 1
st
Account Use Percentage
Pay
Order
Bank Name/Address/Phone
Acct.
Type
Routing
Number
Account
Number
Amount Pct.
1
Ckg
Sav
2
Ckg
Sav
3
Ckg
Sav
TOTAL: _____________
Please attach a voided check or deposit slip for each bank account to which funds will be deposited.
Example Routing Number: 123456789 Example Account Number: 022999999999
Employers: Keep for your records.
For additional information, see Instructions: Additional Forms > Direct Deposit Authorization
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