Direct Deposit Authorization Form:
On this day I have been notified of my options of payment methods. I give consent to the above listed employer to
pay my wages through Direct Deposit to a financial institution that I have selected.
Bank Name: ____________________________
City, State: ____________________________
Routing Transit #: ____________________________
Account Number: ____________________________
Checking Savings
I hereby authorize my employer to make periodic payments in the amount(s) specified above to my account(s) at
the financial institution(s) (hereinafter Bank) indicated on this form. This authority will remain in force until I have
given written notice that I have terminated it or until my employer has notified me that this deposit service has
been terminated. In the event that my employer notifies the bank that funds to which I am not entitled have been
deposited to my account in error, I authorize and direct the bank to return said funds to my employer as soon as
possible. If the funds erroneously deposited to my account have been drawn from that account so that return of
those funds by the bank to my employer is not possible, I authorize my employer to recover those funds by setting
off the amount erroneously paid me from any future payments from my employer until the amount of the erroneous
deposit has been recovered in full.
Print Employee Name:
____________________________
Employee Signature:
____________________________
Date:
_______________
