Direct Deposit Authorization Form

I hereby authorize [Company Name] to directly deposit my pay in the bank account(s) listed below in the percentages specified. (If two accounts are designated, deposits are to be made in whole percentages of pay to total 100%.) I have attached a voided check (checking accounts) or deposit slip (savings accounts) for each account specified below. No more than two accounts may be designated. This authorization is to remain in force until [Company Name] has received written authorization from me of its termination or change. Also, I hereby grant [Company Name] the right to correct any such electronic funds transfer resulting from an erroneous overpayment by debiting my account to the extent of such overpayment.

Employee name (printed): _________________________________________

Signature: __________________________________ Date: ______________

Account #1 (Check only one)

[] Checking (attached voided check)

[] Savings (attach deposit slip and obtain ABA routing number from your bank)

Financial institution: __________________________________________________

Street address: _____________________________________________________

City, State and Zip code: _____________________________________________

Telephone: (_____) ________________

Amount of pay to be deposited into this account:

$_____________ or ________%

Account #2 (Check only one)

[] Checking (attached voided check)

[] Savings (attach deposit slip and obtain ABA routing number from your bank)

Financial institution: __________________________________________________

Street address: _____________________________________________________

City, State and Zip code: _____________________________________________

Telephone: (_____) ________________

Amount of pay to be deposited into this account:

$_____________ or ________%