Direct Deposit Authorization Form

Please complete this Direct Deposit Authorization Form to authorize your employer to deposit your paycheck directly into your bank account.

I am a RETURNING EMPLOYEE and authorize XYZ Co. to reinstate automatic deposits to the SAME ACCOUNT(S) as was done during my most recent employment. (If Yes, skip Account Information section but sign and date this form)

AUTHORIZATION FOR DIRECT DEPOSIT STATEMENT: I hereby authorize XYZ Co. to initiate automatic deposits to my account at the financial institution named below, (or) if I am a returning employee, I authorize XYZ Co. to make withdrawals from this account in the event a credit entry is made in error.

I agree not to hold XYZ Co. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution in depositing funds to my account.

This agreement will remain in effect until XYZ Co. receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated direct deposit form to Human Resources.

I agree to the above Authorization for Direct Deposit Statement

Personal Banking Information

Account

Name of Financial Institution

Routing Number

Account Number

Dollar Amount to be Deposited

Account Type ( Checking/ Savings)

Account 1

Account 2

Account 3

Under penalties of perjury, I declare that I have examined this Authorization for Direct Deposit Form, and to the best of my knowledge and belief, it is true, correct, and complete. I understand this authorization is not valid unless I sign and date below:

Employee Electronic Signature

Name: First Name Last Name

Date:

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