DIRECT DEPOSIT AUTHORIZATION FORM Employee Name: I

DIRECT DEPOSIT AUTHORIZATION FORM
Employee Name: ___________________________________________________________
I hereby authorize Top Prospect Group, Inc. to deposit my pay directly into the bank account(s) listed
below. I have attached a voided check or deposit slip for each account so bank transit and account
numbers can be verified.
I also authorize Top Prospect Group, Inc. to correct any erroneous payment or overpayment to my
account(s) by withdrawing funds in the amount of the excess payment.
This authorization remains in effect until Top Prospect Group, Inc. has received written authorization
from me of its termination or change.
Employee Signature: ______________________________________ Date: ______________
NOTE: If your joint account requires both account holders to sign checks or authorize payments, the
joint account holder must indicate their agreement with the above terms by signing below:
Financial Institution/Account Number(s):
Account 1: ________________________________ ________________________________
Routing Number
Account Number
Account 2: ________________________________ ________________________________
Routing Number
Account Number
Name of Joint Account Holder: ___________________________________________________
Please print
Signature of Joint Account Holder: ________________________________ Date: ___________
Account Information – Form for Account 1
Complete only this form for Account 1 if you want all of your pay deposited into a single account. If you
want your pay per pay period deposited into two accounts, complete both this form for Account 1 and
the form for Account 2.
Account Type:
 Checking
 Savings (Select one)
Name of Financial Institution:____________________________________________________
_________________________________________________________________________
Street Address
City, State, and Zip Code
Telephone Number for Financial Institution: _________________________________________
Percentage or Amount per Pay Period to Deposit for this Account: __________________________
(Use when pay is split between two accounts e.g. 100% or 90% and 10%)
Confirm Account 1: __________________________ ______________________________
Routing Number
Account Number
Company Use Only—Bank/ABA Number: __________________________________________
Account Information – Form for Account 2
Complete only this form for Account 1 if you want all of your pay deposited into a single account.If you
want your pay per pay period deposited into two accounts, complete both this form for Account 1 and
the form for Account 2.
Account Type:
 Checking
 Savings (Select one)
Name of Financial Institution:____________________________________________________
Address of Financial Institution:__________________________________________________
Street Address
___________________________________________________
City, State, and Zip Code
Telephone Number for Financial Institution: _________________________________________
Percentage or Amount per Pay Period to Deposit for this Account: __________________________
(examples: 100%; $350)
(Use when pay is split between two accounts)
Confirm Account 1: __________________________ ______________________________
Routing Number
Account Number
Company Use Only—Bank/ABA Number: __________________________________________