Virginia Direct Deposit Form 3

EMPLOYEE DIRECT DEPOSIT AUTHORIZATION Agency Name:
Employee ID #: _ _ _ _ _ _ _ _ _
Print Employee Full Name:
I wish to have my employer deposit my net pay and/or a fixed amount(s) each payday directly to my account(s) as
indicated. I agree to notify my employer immediately of any changes to the information so that my pay may be properly
distributed. I understand that in the event my employer notifies my financial institution that I am not entitled to the funds
deposited to my account, my bank is authorized to debit my account for the amount of the adjustment. I understand that
in the event my financial institution is not able to deposit any electronic transfer into my account due to any action I take;
that I am responsible for any resulting bank fees incurred, and that my employer can not issue the payroll funds to me
until the funds are returned to my employer by my financial institution.
As required by the Federal Office of Foreign Asset Control in support of U.S.C. Title 50, War and National Defense, I
attest that the full amount of my direct deposit is not being forwarded to a bank in another country and that if at any point I
establish a standing order for my receiving bank to forward the full direct deposit to a bank in another country, I will inform
my employing agency immediately.
Please note that, due to timing differences, new or changed direct deposits may result in one paper check after this form has
been submitted. Please do not close your account(s) without giving your payroll office two weeks prior notice.
Employee Signature
Date
CHECKING ACCOUNTS. Attach a voided check for each account. If a voided check is not attached, this
section should be completed by your financial institution along with their name and signature in Savings below**.
† NET Direct Deposit to the following CHECKING account:
† New
_________________________ ______________________ ______________________ ___NET_______ † Change
Name of Financial Institution
Routing Number
Checking Account Number
Amount
† Stop
† FIXED Amount to the following CHECKING account(s):
† New
† Change
† Stop
† New
_________________________ ______________________ ______________________ ____________ † Change
Routing Number
Checking Account Number
Amount
† Stop
Name of Financial Institution
† New
_________________________ ______________________ ______________________ ____________ † Change
Name of Financial Institution
Routing Number
Checking Account Number
Amount
† Stop
_________________________ ______________________ ______________________ ____________
Name of Financial Institution
Routing Number
Checking Account Number
Amount
SAVINGS ACCOUNTS. Deposit slips can NOT be used. This section and the routing and account numbers
below should be completed by your financial institution.
**Print name of Financial Representative: ____________________________________
Phone: _______________
**Signature of Financial Representative:
Date:
____________________________________
_______________
† NET Direct Deposit to the following SAVINGS account:
† New
_________________________ ______________________ ______________________ ___NET_______ † Change
Name of Financial Institution
Routing Number
Savings Account Number
Amount
† Stop
† FIXED Amount to the following SAVINGS account(s):
† New
† Change
† Stop
† New
_________________________ ______________________ ______________________ ____________ † Change
Name of Financial Institution
Routing Number
Savings Account Number
Amount
† Stop
† New
_________________________ ______________________ ______________________ ____________ † Change
Name of Financial Institution
Routing Number
Savings Account Number
Amount
† Stop
_________________________ ______________________ ______________________ ____________
Name of Financial Institution
Routing Number
Savings Account Number
Amount
To be completed by the Agency Payroll Section:
Checking deduction numbers: fixed 159, 163, 167. Net checking 169
CIPPS Updated by: ___________ Date ___/___/___
Savings deduction numbers: fixed 160, 164, 168. Net savings 170
Reviewed by: ______________ Date ___/___/___
10/10