AUTHORIZATION FOR AUTOMATIC DEPOSIT
Pay day is Thursday
Properly authorized time-sheet(s) must be received at A.R. Mazzotta Employment Specialists payroll department prior to Monday 11:00 AM in order to receive direct deposit that week. Timecards received after this time may not be processed until next pay period.
· The undersigned hereby authorizes A.R. Mazzotta Employment Specialists to make deposits from time to time in the account(s) identified below and authorizes the Bank to accept such deposits. It is agreed that these deposits may be made electronically and under the rules of the Automated Clearing House Association (ACHA).
· From time to time for reasons such as, but not limited to, holidays when financial institutions are closed direct deposit may occur at a later day that week.
· In the event that money not due to me is directly deposited to my bank account, I agree to repay the funds to A.R. Mazzotta Employment Specialists.
· I understand that direct deposit pay advice contains confidential information such as but not limited to hourly rate of pay, hours worked, taxes, year-to-date earnings, and gross and net pay.
After this form is received at A. R. Mazzotta Employment Specialists Payroll Department there will be a one week pre-note period.
*Checking Account # _______________________________ Amount/percent ___________________
Name of Bank: ____________________________________ Routing # ________________________
**Savings Account # _______________________________ Amount/percent ___________________
Name of Bank: ____________________________________ Routing # ________________________
Attaching a voided check or bank spec sheet is preferred.
We require written notice either faxed or emailed to payroll in order to stop direct deposit.
By signing this document I understand the above and give permission to email my direct deposit pay advice to the confidential email address below.
_______________________________________________ __________________________
(signature) (date)
PRINT: Name____________________________________ SS # XXX-XX-___________________
You will receive a “PAPER” check for the one week trial period before the actual direct deposit begins.
How do you want to receive your first check? Circle your choice
Middletown Pick up * Wallingford Pick up * Watertown Pick up
Westbrook Pick up * MAIL
Confidential Email Address: ___________________________________________________________
06.25.15