DIRECT DEPOSIT AUTHORIZATION FORM
Fill in the boxes below and sign the form.
Last NameFirst NameM I
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Social Security Number
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Work Phone
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Name of Financial Institution
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Account Number |
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Type of Account |
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Savings |
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Checking |
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Routing Transit Number
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(All 9 boxes must be filled. The first two numbers |
Ownership of Account |
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must be 01 through 12 or 21 through 32.) |
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Self |
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By signing this agreement, I authorize ____________________ to initiate credit entries to the account indicated above for the purpose of expense and/or payroll.
I also authorize ______________________________ to initiate, if necessary, debit entries and adjustments for any credit entries made in error.
Signature ____________________________________________________________________________________ Date ___________________
If the account is a joint account or in someone else's name, that individual must also agree to the terms stated above by signing below.
Signature ____________________________________________________________________________________ Date ___________________
HOW TO COM PLETE THIS FORM
1.Fill in all boxes above.
2.Sign and date the form.
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TIP |
Call your financial institution to |
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JOHN PUBLIC |
1234 |
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make sure they will accept direct |
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0 deposit s. |
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123 MAIN STREET |
19 |
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YOUR TOWN, FL 12345 |
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Verify your account number and |
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PAY TO THE |
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routing transit number with your |
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ORDER OF |
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0 financial institution |
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$ |
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YOUR TOWN BANK |
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DOLLARS |
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Do not use a deposit slip to verify |
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YOUR TOWN, FL 12345 |
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0 the routing |
number. |
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FOR |
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IRouting Transit Number |
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Account |
l~::::::::,(~::250000005::)•:(~:=1234556789022~):..1·___________ J |
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Number |
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NOTE: THE ACCOUNT AND ROUTING NUM BER M AY APPEAR IN DIFFERENT PLACES ON YOUR CHECK.