Save As Print Form EMPLOYEE DIRECT DEPOSIT FORM UCP provides direct deposit of paychecks for all employees. In order to ensure employees are paid appropriately, we ask that the following information be completed. Account Information: UCP can set up your payments to be distributed to one or multiple accounts. Please attach information directly from your bank validating your information (Voided check, deposit slip, bank statement, etc.) 1. Bank Name/City/State: Routing/Transit #: Account Number: □ Checking I wish to deposit: 2. □ Savings □ Entire Net Amount or $ Bank Name/City/State: Account Number: Routing/Transit #: □ Checking I wish to deposit: 3. □ Other: _____________________ □ Savings □ Other: _____________________ □ Entire Net Amount or $ Bank Name/City/State: Account Number: Routing/Transit #: □ Checking I wish to deposit: □ Savings □ Other: _____________________ □ Entire Net Amount or $ Authorization: I hereby authorize United Cerebral Palsy of Greater Dane County (“UCP”) to deposit any amounts owed me by initiating credit entries to my accounts at the financial institutions (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by UCP to my accounts. In the event that UCP deposits funds erroneously into my account, I authorize UCP to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until UCP and Bank have received written notice from me of its termination in such time and in such manner as to afford UCP and Bank reasonable opportunity to act on it. ____ Employee Name (please print) Employee Signature ____________ Date Please return this form to the UCP office attention Human Resources. We ask that you submit this form independent of other paperwork to ensure proper processing. • Mail: UCP, Attn: Human Resource, 2801 Coho St., 300, Madison, WI 53713 • Email: [email protected] • Fax: (608)273-3426, Attn: Human Resources.
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