Direct Deposit Authorization Form
Send To:
Employer Name:
Attention: Payroll/Human Resources Department
Employer Address:
Employer City:       State:             Zip: 
For:
Employee Last:      First: 
Address:
City:          State:              Zip:

Fill out and print this form and send to your employers Human Resources/Payroll department WITH A COPY OF A VOIDED CHECK from the account you want your payroll checks deposited into.  By including a voided check, we can make sure there will not be any errors in account numbers or routing numbers.  If you want your checks deposited into an account where you do not have checks available, please come and see a New Accounts representative at one of our locations for a form to set this up.

Please do not forget to sign the authorization below once your have printed and reviewed that all information is correct.

Routing and Transit Number

Account Number

Account Type
Checking  Savings

 

checknumbers.gif (1937 bytes)

 

I (we) hereby authorize my employer to initiate electronic credit entries, and if necessary debit entries and adjustments for any credit entries in error to my (our) account indicated above.

Signature:  _______________________________         Date:  ____/____/_______

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