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DIRECT DEPOSIT AUTHORIZATION
Full Legal Name: ______________________________________
Identification Number: ______________________________________
Social Security Number: ______________________________________
Bank Name/Branch: ______________________________________
Account Number: ______________________________________
Check the appropriate item:
_____ Direct deposit.
The undersigned hereby requests and authorizes the entire amount of my paycheck each pay period to be deposited directly into the bank account named above.
_____ Direct payroll deduction deposit.
The undersigned hereby requests and authorizes the sum of ___________________________________________ dollars ($___________ ) be deducted from my paycheck each pay period and to be deposited directly into the bank account named above.
_____ I would like to cancel my deposit authorization.
The undersigned hereby cancels the authorization for direct deposit or payroll deduction deposited previously submitted.
Employee Signature Date
(Please attach a copy of deposit slip.)
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