Direct Deposit Authorization Agreement
I hereby authorize ABC Company to initiate direct deposit to the account(s) indicated below. If necessary, I authorize the company to initiate debit entries and adjustments for any direct deposit entries in error to the account(s) indicated below.
PRIORITY 1
Depository Name: ________________________________________________________
City: ___________________ State: _____________________ Zip: _____________
Bank Routing Number: ____________________________________________________
Account Number: _________________________________________________________
Checking? _____ Saving? _____
Select One:
Fixed Amount ($) __________ Entire Net ($)__________
PRIORITY 2
Depository Name: ________________________________________________________
City: ___________________ State: _____________________ Zip: ______________
Bank Routing Number: ____________________________________________________
Account Number: _________________________________________________________
Checking? _____ Saving? _____
Select One:
Fixed Amount ($) __________ Entire Net ($) __________
This authority is to remain in effect until the company has received written notification from me of its termination in such time and in such manner as to afford the company a reasonable time to act on it.
Name: (print) _______________________________ SSN: ___________________
Signature: __________________________________ Date: ___________________
Note: Attach a voided blank check and/or savings account deposit slip to validate account information.
This form is an example. It is not a “model” form; it has not been reviewed by attorneys; and it does not necessarily reflect the employment laws in any or all of the fifty states. We urge you to use this as a sample, not a model; adapt it to your own organization’s policies, practices, and culture; and above all, have any new form reviewed by legal counsel.