Electronic Funds Transfer Form
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I authorize my Employer to directly deposit my paycheck into the bank account or accounts listed below and in the percentages as specified. Designated deposits to more than one account shall be made in whole percentages and equal 100%. A voided check or deposit slip has been attached to this form for each account that is listed below. This authorization is to remain in effect until the company receives written authorization from me that it is terminated or changed. I also grant my Employer the right to correct any Electronic Funds Transfer overpayment and give the Employer the ability to deduct any excess funds from the accounts listed below that do not rightfully belong to me.
Name:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Telephone: (______)_________________
_______________________ Date_____
Employee Signature
Account #1) Checking [___] or Savings [___]
Financial Institution:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Telephone: (______)_________________
Percent of pay check to be deposited into Account #1):_____%
Bank Account #
________________________________
ABA Routing #
________________________________
Account #2) Checking [___] or Savings [___]
Financial Institution:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Telephone: (______)_________________
Percent of pay check to be deposited into Account #2):_____%
Bank Account #
________________________________
ABA Routing #
________________________________
Company Use Only:
Effective Date:
_____/_____/_______
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