Direct Deposit Authorization Form CHECK APPROPRIATE BOXES

Direct Deposit Authorization Form
I (we) hereby authorize the Payroll Center, LLC, hereinafter called COMPANY, to initiate credit entries to
my (our) account indicated below and the financial institution named below, hereinafter called
DEPOSITORY, to credit the same to such account. This authority is to remain in full force and effect until
COMPANY has received written notification from me (or either of us) of its termination in such time and
in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
Name
Social Security Number
Financial Institution Name
Date
Branch Location
Signature
CHECK APPROPRIATE BOXES:
My account type is:
[ ] Checking, Money Market, Other
[ ] Savings Account
I am not currently participating in the Direct Deposit Program
[ ] ADD – Deposit my pay to the account shown.*
[ ] PARTIAL – Deposit a portion of my pay into the account shown ($ or % ____________ )
I am currently participating in the Direct Deposit Program
[ ] CHANGE – Change financial institution and/or account number.*
[ ] CANCEL – Stop my participation in the program.
TAPE YOUR VOIDED CHECK HERE