Direct Deposit Authorization
DIRECT DEPOSIT AUTHORIZATION
Employee Name ______________________
Social Security Number ________________
Financial Institution Name ______________
Account Number ______________________
Please check the appropriate box below. Requests must be submitted ___________ before the end of the pay period in order to take effect for that pay period. Requests that are not submitted far enough in advance will take effect on the pay period that follows the current pay period. Please attach a copy of a deposit slip for the account you want your deposit to go to.
( ) Direct deposit. I request and authorize the entire amount of my paycheck
each pay period to be deposited directly into the account named above.
( ) Direct payroll deduction deposit. I request and authorize the sum of ___________ dollars [ $_ _ _ _ _._ _ ]to be deducted from my paycheck each pay period and to be deposited directly into the account named above.
( ) I would like to cancel my deposit authorization. I cancel my authorization for direct deposit or payroll deduction deposit.
Employee Signature Date
These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.