Direct Deposit Authorization

Name: _____________

Tax Identification Number: ________

Asa matter of convenience to our employees, the [Company] can direct deposit either a portion of or your entire payroll to the financial institution of your choice.

[ ] Please Direct Deposit my entire net payroll check to:

Name of Bank and Branch:_________________

Account Number:__________________________

Routing Number:__________________________

I, [state full name] do hereby request the deposit of my entire net payroll check into the above named bank account each pay period. I further authorise ______________ and ___________ to withdraw any funds deposited in error into my account.

[ ] Please deposit a portion of my payroll through a Direct Payroll Deduction to:

I hereby request and authorise the sum of __________ to be deducted from my paycheck each pay period, and to be deposited directly into the bank account named above. I further authorise ________ and ________ to withdraw any funds deposited in error into my account.

[ ] I would like to cancel my deposit authorisation. I hereby cancel the previously submitted authorisation for direct deposit and/or payroll deduction deposit .

Employee Signature ________________________

Date

copy of deposit slip attached.