Direct Deposit Enrollment / Change Form - Checkwise Payroll - New York

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DIRECT DEPOSIT ENROLLMENT / CHANGE FORM
Employee Name: _______________________________________________________________
SSN: XXX-XX-_________
Bank Name
Account #
Account Type
I wish to deposit:
COMPLETE THE INFORMATION BELOW TO ENROLL OF CHANGE ENROLLMENT IN DIRECT DEPOSIT
Remainder of Net Pay
________ % of Net
Checking
Specific Amount $ _________
Remove from Direct Deposit
Savings
Remainder of Net Pay
________ % of Net
Checking
Specific Amount $ _________
Remove from Direct Deposit
Savings
ATTACH ONE OF THE FOLLOWING FOR EACH ACCOUNT INDICATED ABOVE.
Voided copy of a check
Deposit slip ( only if “ACH/RT” is displayed)
Bank letter or specification Sheet signed by a bank representative
EMPLOYEE AUTHORIZATION STATEMENT
I hereby authorize my employer to deposit my wages into the bank account(s) indicated on this form and initiate
(if necessary) debit entries or adjustments for any credit entries in error to my account. I attest that the associated
transactions authorized under this agreement will not be international ACH transactions (IAT). IATs shall include
credit or debit entries involving a financial agency (an entity authorized to accept deposits, transfer funds, or issue
money orders), if the office of financial agency that is involved in the payment transaction (holding accounts that
are debited or credited, receiving or making payments or serving as an intermediary in any part of the
transaction) is outside of the US.
EMPLOYEE SIGNATURE:
DATE:
COMPANY APPROVAL
COMPANY NAME:
COMPANY SIGNATURE:
DATE:
DIRECT DEPOSIT ENROLLMENT / CHANGE FORM
Employee Name: _______________________________________________________________
SSN: XXX-XX-_________
Bank Name
Account #
Account Type
I wish to deposit:
COMPLETE THE INFORMATION BELOW TO ENROLL OF CHANGE ENROLLMENT IN DIRECT DEPOSIT
Remainder of Net Pay
________ % of Net
Checking
Specific Amount $ _________
Remove from Direct Deposit
Savings
Remainder of Net Pay
________ % of Net
Checking
Specific Amount $ _________
Remove from Direct Deposit
Savings
ATTACH ONE OF THE FOLLOWING FOR EACH ACCOUNT INDICATED ABOVE.
Voided copy of a check
Deposit slip ( only if “ACH/RT” is displayed)
Bank letter or specification Sheet signed by a bank representative
EMPLOYEE AUTHORIZATION STATEMENT
I hereby authorize my employer to deposit my wages into the bank account(s) indicated on this form and initiate
(if necessary) debit entries or adjustments for any credit entries in error to my account. I attest that the associated
transactions authorized under this agreement will not be international ACH transactions (IAT). IATs shall include
credit or debit entries involving a financial agency (an entity authorized to accept deposits, transfer funds, or issue
money orders), if the office of financial agency that is involved in the payment transaction (holding accounts that
are debited or credited, receiving or making payments or serving as an intermediary in any part of the
transaction) is outside of the US.
EMPLOYEE SIGNATURE:
DATE:
COMPANY APPROVAL
COMPANY NAME:
COMPANY SIGNATURE:
DATE:

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