Authorization for Direct Deposit

I authorize __________________________________________to deposit my pay

automatically to the account(s) indicated below and, if necessary, to adjust or reverse a

deposit for any payroll entry made to my account in error. This authorization will remain in

effect until I cancel it in writing and in such time as to afford

_______________________________________________ a reasonable opportunity to act

on it.

Name on bank account: ___________________________________________________

Bank account number: _______________________________Checking ___ Savings ___

Bank routing number: __________________________

Amount: $ ___________________ or entire paycheck: ___

*Balance of pay to:

_________ Manual (paper check)

_________ Account described below

*Note: Split payments are not available for contractors.

Name on bank account: ___________________________________________________

Bank account number: _______________________________Checking ___ Savings ___

Bank routing number: __________________________

Important: Please attach a voided check for each bank account to which funds should be

deposited.

Employee/Contractor signature: _____________________________________________

Date: _____________________

Payers: Do not send this form with your Direct Deposit enrollment. Keep for your

records.