DIRECT DEPOSIT AUTHORIZATION FORM
Fill in the boxes below and sign the form.
Last NameFirst NameM I
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Social Security Number
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| Action | □ □ | Effective Date | 
| □New | □□ □□ □□ | 
|   | ChangeCancel | M onthDayYear | 
 
Work Phone
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Name of Financial Institution
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| Account Number | (Include hyphens but omit spaces and special symbols.) | Type of Account |   | 
|   | Savings | 
|   |   | Checking | 
| □□□□□□□□□□□□□□□□□ | □ | □ | 
 
Routing Transit Number
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| (All 9 boxes must be filled. The first two numbers | Ownership of Account |   | 
|   |   |   |   |   | 
| must be 01 through 12 or 21 through 32.) |   |   |   |   |   | 
|   |   |   |   |   |   | 
|   | Self | Joint | Other | 
|   | □ | □ | □ | 
 
 
By signing this agreement, I authorize ____________________ to initiate credit entries to the account indicated above for the purpose of expense and/or payroll.
I also authorize ______________________________ to initiate, if necessary, debit entries and adjustments for any credit entries made in error.
Signature ____________________________________________________________________________________ Date ___________________
If the account is a joint account or in someone else's name, that individual must also agree to the terms stated above by signing below.
Signature ____________________________________________________________________________________ Date ___________________
HOW TO COM PLETE THIS FORM
1.Fill in all boxes above.
2.Sign and date the form.
|   | TIP | Call your financial institution to |   | JOHN PUBLIC | 1234 |   | 
|   | make sure they will accept direct |   |   |   |   |   |   | 
|   |   |   |   |   |   |   |   |   | 
| 0 deposit s. |   | 123 MAIN STREET | 19 |   |   |   |   | 
|   |   |   |   |   | YOUR TOWN, FL 12345 |   |   |   |   |   | 
|   | TIP | Verify your account number and |   | PAY TO THE |   |   |   |   |   | 
|   | routing transit number with your |   | ORDER OF |   |   |   |   |   | 
| 0 financial institution |   |   |   |   | $ |   |   |   | 
|   |   |   |   |   |   | 
| YOUR TOWN BANK |   |   |   | DOLLARS | 
|   | TIP | Do not use a deposit slip to verify |   |   |   |   |   |   |   |   | 
|   | YOUR TOWN, FL 12345 |   |   |   |   |   | 
|   |   |   |   |   |   |   |   | 
|   | 0 the routing | number. |   | FOR |   |   |   |   |   | 
|   |   |   |   |   |   |   |   |   |   |   |   | 
| IRouting Transit Number | I |   | ➤ | 
| I | Account | l~::::::::,(~::250000005::)•:(~:=1234556789022~):..1·___________ J | 
|   |   | Number | ➤ | 
 
NOTE: THE ACCOUNT AND ROUTING NUM BER M AY APPEAR IN DIFFERENT PLACES ON YOUR CHECK.