Forms > Payroll Direct Deposit Form

Payroll Direct Deposit Form

The payroll direct deposit form is used for the authorization for both net pay deposits and also other flat amount deposits. The deposits are made to the individual’s account and the institution can only do this with the consent of the applicant. Below is a sample payroll direct deposit form.

Sample Payroll Direct Deposit Form

Social security number: ___________________________

Full Name: ___________________________

ELECTRONIC FUND TRANSFER (EFT) AUTHORIZATION

NET PAY DEPOSIT: (INITIAL AUTHORIZATION/ CHANGE/ CANCELLATION/ NO CHANGE) ___________________________

Financial institution name: ___________________________

Institution transit routing number: ___________________________

Account number: ___________________________

SAVINGS_____________

CHECKING-attach a voided check: ___________________________

FREQUENCY (PICK ONE ONLY)

1^ST payroll of month (16^th –end of month pay period) ___________________________

2^ND payroll of month (1^st-16^th pay period) ___________________________

Any alteration or unauthorized addition invalidates this form.

By signing this document I am affirming to the information filled out on the form and affirm liability.

Signed: ___________________________

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