DIRECT DEPOSIT AUTHORIZATION FORM I hereby authorize St

DIRECT DEPOSIT AUTHORIZATION FORM
I _________________________________________ hereby authorize St. John Health to deposit my
Print Name
paycheck into the specified account(s) below.
__________________________________________
Signature
________________________
Social Security #
__________________________________________
Associate ID #
________________________
Date
To activate a direct deposit request, a minimum of two pay periods is required. You will receive a live check during this
transitional period. Complete the appropriate sections below and return to the Payroll Department. Please attach a voided check
for a checking account or obtain the transit/bank routing number for a savings account (contact your financial institution to
obtain). Deposit slips are not accepted.
Your deposit(s) will be shown in the “Current Deductions” column of your pay advice. You may deposit into multiple financial
institutions and/or accounts. If you close an account, please notify the Payroll Department immediately. In the event of an
error, St. John Health is authorized to make the necessary adjustment to your account(s).
NEW ACCOUNT
Primary Deposit:
Routing #_____________________________Account #_______________________
Bank/Inst._____________________________
Checking or Savings (Circle One)
Additional Deposit:
$ Amount or %__________ Routing #_____________________________Account #_______________________
Bank/Inst._____________________________
Checking or Savings (Circle One)
Additional Deposit:
$ Amount or %__________ Routing #_____________________________Account #_______________________
Bank/Inst._____________________________ Checking or Savings (Circle One)
CHANGE EXISTING ACCOUNT
Change the deposit amount from $/%_______________ to $/%_______________ for account #______________________
Change the deposit amount from $/%_______________ to $/%_______________ for account #______________________
Change the deposit amount from $/%_______________ to $/%_______________ for account #______________________
CANCEL EXISTING ACCOUNT
Account #____________________________
Account #____________________________
RETURN THIS COMPLETED FORM TO:
St. John Health
Attn: Payroll Department
28000 Dequindre Road
Warren, MI 48092
Or FAX to our SECURE FAX Machine: (586) 753-0351