Employee Direct Deposit Authorization Form

Employee Direct Deposit Authorization
Please print legibly
Employee Name
Employer Name
Social Security Number
Daytime Phone Number
EXT____________
Bank Account Information:
Please attach one of the following for Checking or Savings accounts:
Voided check with name imprinted
Deposit slip (only accepted if "ACH R/T" appears before the routing number)
Bank letter or specification sheet
Account #1
Account #2
Percentage of net pay:*
Percentage of net pay:*
OR amount of net pay:**
OR amount of net pay:**
Bank Name:
Bank Name:
Bank Routing Number:
Bank Routing Number:
Bank Account Number:
Bank Account Number:
Type of Account:
Checking
Savings
Type of Account:
Checking
Savings
* If all percentages do not add to 100% a check will be issued for the remainder
** When indicating dollar amounts to more than one account, any remainder will be issued by check. Any shortage will be
taken from account #2. "Remainder" may be entered if you wish your entire net pay to be directly deposited.
I hereby authorize my employer, ____________________________ and its assigns (hereinafter COMPANY), to deposit any amounts owed me by
initiating credit entries to my account at the financial institution (hereinafter BANK) indicated above. Further, I authorize BANK to accept and to credit
any credit entries indicated by COMPANY to my account. In the event that COMPANY deposits funds erroneously into my account, I authorize
COMPANY to debit my account for an amount not to exceed the original amount of the erroneous credit.
For my convenience, I request that COMPANY directly deposit my wages/salary earned from my employer into my bank account. I understand that
deposit of my earnings into my account may be an advance of funds by a third party on behalf of my employer, which is subject to the successful
collection of these funds from my employer's bank. If, within 30 days of any third party making the deposit into my account my employer does not
make available to any third party the funds that were advanced to make the deposit into my account, I authorize that third party to charge my account to
recover said advance. I agree to hold such third party harmless from loss and to indemnify it, limited to the amount of the deposit.
Any dispute arising out of or in connection with this agreement, if not otherwise resolved, shall be determined by arbitration in Cincinnati, Ohio, in
accordance with the Rules of the American Arbitration Association, and it is the expressed desire of both parties that the prevailing party be
awarded costs and attorney's fees and that the award be entered as a judgement in any jurisdiction in which the non-prevailing party does
business.
This authorization is to remain in full force and effect until COMPANY and BANK have received written notice from me of its termination in such time and
in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
Employee Signature
Date