You can have employees
complete this sample form to authorize direct deposit of their paychecks. Keep
in mind that you cannot require employees to use direct deposit.
Direct Deposit Authorization Form
Employees may elect to
authorize a full or partial deposit of earned wages to checking or savings
accounts at up to [specify number] different banks, savings and loan
institutions, or credit unions.
If you are designating
an account, you must: 1) already have the account set up at your bank; 2) find
out if the bank accepts direct deposits; and 3) verify the bank’s routing
transit number (or “ABA”) and your account number (including dashes). You must
also notify the bank that you are going to set up direct deposit through payroll.
Make sure that you check whether your bank has special requirements for setting
up direct deposit.
Please check the action
you wish to take and fill out the form below. Return this form to [department]
with a voided check from your checking account or a deposit slip from your
savings account.
__ New account (complete
A-E below).
__ Replacing existing
account (complete A-E below). Specify account you are replacing:
__ Changing amount of
direct deposit (complete C-E below).
__ Canceling account
(complete C below). Do not close an account until you cancel the direct deposit
authorization for the account. Processing of your request may take up to two
pay periods.
Information for Account
#1:
A. Bank Name _________________
B. Bank
C. Bank Account #
____________________
D. (check one) ____Checking
____Savings
E. __ Full Deposit
__ Partial Deposit (amount per pay period) $____ or ____%
__ Partial Deposit (balance of net pay)
Information for Account
#2:
A. Bank Name _________________
B. Bank
C. Bank Account #
____________________
D. (check one) ____Checking
____Savings
E. __ Full Deposit
__ Partial Deposit (amount per pay period) $____ or ____%
__ Partial Deposit (balance of net pay)
Use additional forms for
direct deposits to additional accounts. Up to [specify number] accounts may be used
for direct deposit. If you are designating dollar amounts, be sure that one
account provides for deposit of net pay balance; if using percentages, be sure
that designated percentages add up to 100 percent.
Your direct deposit will
usually be effective the second pay period after it was entered. If you are
terminating or changing an authorization, please allow sufficient time for the
change to take effect.
I authorize [Company]
and the bank(s) listed above to deposit my net pay or portion thereof as
indicated above into my account(s) each payday. If funds to which I am not
entitled are deposited to my account, I authorize [Company] to direct the
bank(s) to return said funds.
I understand that some
banks do not post funds until the afternoon; therefore, my deposit may not be
credited to my account until the afternoon of the pay date indicated on the
check. I understand that it is my responsibility to ensure that my wages are
being deposited correctly into my account each payday.
I understand that this
authorization will remain in effect until I replace it with a substitute
authorization, notify [Company] in writing that I am terminating this
authorization, or [Company] notifies me in writing that it is canceling this
authorization. I further understand that at [Company’s] discretion, this
authorization may not apply to final wages due upon termination of my
employment.
Employee Name:______________________________________
Signature:___________________________________
Date:______________________
………………………………………………………………
For payroll purposes
only:
Date Entered: ____________________
By:___________________________________
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