"Direct Deposit Enrollment Form - Affiliated Payroll Services"

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DIRECT DEPOSIT
ENROLLMENT FORM
Employee Information
Employer Information
PLEASE PRINT
PLEASE PRINT
Employer Name:____________________________
Employee Name:_______________________________
Federal ID Number:__________________________
Social Security Number: _________________________
Complete for DIRECT DEPOSIT and attach a VOIDED check. Deposit Slips are not
accepted. Note: If depositing into a Savings Account ask your bank for for the Routing/
Transit Number as the number on the Savings Deposit slip may not be the same.
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #1 - Checking / Savings (Circle one)
Entire Net Amount
Bank Name___________________________________________
______% of Net
Routing Number _______________________________________
Specific Dollar Amount $_______
Account Number_______________________________________
Attach Voided Check Here
_________________________________
____________
Employee Signature:
Date:
By authorizing above, I agree that I am either the accountholder or have the authority of the accountholder to authorize my
employer to make direct deposits into the named account(s) above. Further, I agree that if my employer deposits funds into my
account in error they have the authority to remove those funds via an electronic transaction.
For Office Use Only
Date Received: __________________ Date Prenoted: __________________ Date Accepted:__________________
Comments:________________________________________________________________________________________
DIRECT DEPOSIT
ENROLLMENT FORM
Employee Information
Employer Information
PLEASE PRINT
PLEASE PRINT
Employer Name:____________________________
Employee Name:_______________________________
Federal ID Number:__________________________
Social Security Number: _________________________
Complete for DIRECT DEPOSIT and attach a VOIDED check. Deposit Slips are not
accepted. Note: If depositing into a Savings Account ask your bank for for the Routing/
Transit Number as the number on the Savings Deposit slip may not be the same.
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #1 - Checking / Savings (Circle one)
Entire Net Amount
Bank Name___________________________________________
______% of Net
Routing Number _______________________________________
Specific Dollar Amount $_______
Account Number_______________________________________
Attach Voided Check Here
_________________________________
____________
Employee Signature:
Date:
By authorizing above, I agree that I am either the accountholder or have the authority of the accountholder to authorize my
employer to make direct deposits into the named account(s) above. Further, I agree that if my employer deposits funds into my
account in error they have the authority to remove those funds via an electronic transaction.
For Office Use Only
Date Received: __________________ Date Prenoted: __________________ Date Accepted:__________________
Comments:________________________________________________________________________________________