"Direct Deposit Enrollment Form - Affiliated Payroll Services"

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Download "Direct Deposit Enrollment Form - Affiliated Payroll Services"

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DIRECT DEPOSIT
ENROLLMENT FORM
Employee Information
Employer Information
PLEASE PRINT
PLEASE PRINT
Employee Name:_____________________
Employer Name:_____________________
Social Security Number: _______________
Federal ID Number: __________________
Complete for DIRECT DEPOSIT and attach a VOIDED check(s). 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)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #2 Checking / Savings (Circle One)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #3 Checking / Savings (Circle One)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
________________________
____________
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
Employee Name:_____________________
Employer Name:_____________________
Social Security Number: _______________
Federal ID Number: __________________
Complete for DIRECT DEPOSIT and attach a VOIDED check(s). 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)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #2 Checking / Savings (Circle One)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
I authorize my employer to deposit my wages/salary to the following bank account(s).
Bank Account #3 Checking / Savings (Circle One)
I wish to Deposit (Check One):
Bank Name____________________________
Entire Net Pay
Routing Number ________________________
____ % of Net
Account Number________________________
Specific Dollar Amount $ _______
________________________
____________
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:________________________________________________________________________________________