Exhibit (C) Authorization Agreement For Direct Deposit THIS FORM

Exhibit (C) Authorization Agreement For Direct Deposit
(Copy, complete and sign one for each Account/Bank)
Employer Name
Federal ID #
Employer Address
City
State
Zip
EMPLOYEE NAME ______________________________ EMPLOYEE SS # __________________________
I hereby authorize (my employer),______________________________________hereinafter called EMPLOYER,
to initiate credit entries and to initiate if necessary, debit entries and adjustments for any credit entries in error to
my (our) account or accounts listed below. I acknowledge that the origination of ACH transactions to my account
must comply with the provisions of U.S. law.
Name of bank, credit union or savings & loan
q Checking (OR) q Savings (Choose One)
Routing and Transit Number
q Fixed Amount $ ________________(OR)
Account Number
q Percent of net pay amount __________%
This authorization is to remain in full force and effect until EMPLOYER has received written notification from me
(or either of us) of its termination in such time and in such manner as to afford to EMPLOYER a reasonable
opportunity to act on it.
DATE
NOTE:
______________________
SIGNATURE of Employee ____________________________________
ALL WRITTEN CREDIT/DEBIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE
AUTHORIZATION ONLY BY NOTIFYING THE EMPLOYER IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
THIS FORM IS FOR YOUR INTERNAL USE ONLY
Use this form on your letterhead or have preprinted forms. It is the employer’s responsibility to have this form completed by each employee
that request direct deposit and to keep on file for two years after termination of direct deposit.
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CompuPay, Inc. 1-800-888-5636 • 302 South Royal Oaks Blvd. • Franklin, Tennessee 37064