CLICK HERE FOR A PRINTABLE COPY OF THIS FORM
Then follow the instructions on this page.
After printing out, then sign the printed form and deliver
it to your Employer’s Payroll Department.

Direct Deposit Agreement Form

Authorization Agreement

I hereby authorize [Enter Your Employer’s Name Here] to initiate automatic deposits to my account at the financial institution named below. I also authorize [Enter Your Employer’s Name Here] to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold [Enter Your Employer’s Name Here] responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until [Enter Your Employer’s Name Here] receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
 

Account Information

Signature

Please sign this form and deliver to your Employer’s Payroll Department.