Direct Deposit Authorization Form You must attach a voided check

Direct Deposit Authorization Form
Town of Holly Springs
Name: _______________________________________________
Action Requested: (Check one)

Start Direct Deposit
Employee ID #
Change (add a bank, increase/decrease fixed
amount or select new balance account)

A change replaces the direct deposit authorization currently on file
Fill in every row of bank information to show how your check should now be deposited.
You must attach a voided check or provide a letter from the bank. If you use a deposit slip
you must verify that the routing number is correct.
Bank Name
Routing #
___ ___ ___ ___ ___ ___ ___ ___ ___
Checking
I wish to deposit
$___________.00
(9 digits)
Or
Account #
_______________________________
Savings
Or
Entire Net Amount
If depositing to more than one (1) bank, you must choose one account to deposit entire net amount.
Bank Name
Routing #
I wish to deposit
___ ___ ___ ___ ___ ___ ___ ___ ___ Checking
$___________.00
(9 digits)
Or
Account #
_______________________________
Bank Name
Savings
Or
Entire Net Amount
Routing #
___ ___ ___ ___ ___ ___ ___ ___ ___
Checking
I wish to deposit
$___________.00
(9 digits)
Or
Account #
_______________________________
Savings
Or
Entire Net Amount
I authorize the Town of Holly Springs to deposit my net pay via direct deposit to my account(s) as indicated above. If funds to which
I am not entitled are deposited to my account(s), I authorize the Town of Holly Springs to direct the financial institution(s) to return
said funds.
I understand that it is my responsibility to verify that payments have been credited to my account(s) and that the Town of Holly
Springs assumes no liability for overdrafts for any reason. I understand that in the event my financial institution(s) is/are not able to
deposit any electronic transfer into my account due to any action I take, the Town of Holly Springs cannot issue the funds to me until
the funds are returned to the Town of Holly Springs by my financial institution(s).
I understand I must immediately notify the Human Resources Department before I close any/all account(s) listed above while this
authorization is in effect.
Employee Signature _____________________________________________
Today’s Date ___________________