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Back to Forms for 'Compensation & Benefits'.




Name: _______________________


I.D. Number: _______________________


S.S. Number: _______-_______-_______


As a convenience to our employees, the Company can direct deposit either a portion of or your entire payroll to the financial institution of your choice.  Please note that you are not required to have any portion of your wages deposited directly into a financial institution.


[   ] Yes, Please Direct Deposit my entire net payroll check to:


Bank Name & Branch __________________ Account Number ____________________


I hereby request the deposit of my entire net payroll check into the above named bank account each pay period.  I further  authorize ___________________________ and _________________________ to withdraw any funds deposited in error into my account.


[   ] Yes, please deposit a portion of my payroll through a Direct Payroll Deduction to:


Bank Name & Branch: __________________ Account Number: ___________________


I hereby request and authorize the sum of ________________ Dollars ($________) to be deducted from my paycheck each pay period, and to be deposited directly into the bank account named above.

I further authorize ________________________ and ________________________ to withdraw any funds deposited in error into my account.


[   ]  I would like to cancel my deposit authorization.  I hereby cancel the previously submitted authorization for direct deposit and/or payroll deduction deposit .


Employee Signature: ________________________           Date: __________________


Please attach a copy of deposit slip.


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