DIRECT DEPOSIT AUTHORIZATION FORM

Employee information

• Employee name: [EMPLOYEE NAME]
• Employee ID: [ID]
• Department: [DEPARTMENT]
• Action: [ ] New setup [ ] Change accounts [ ] Cancel direct deposit

Primary account (net pay destination)

• Bank name: ___________________________
• Account type: [ ] Checking [ ] Savings
• Routing number (9 digits): ___________________________
• Account number: ___________________________
• Deposit: [ ] Entire net pay [ ] $ __________ per pay period

Secondary account (optional split)

• Bank name: ___________________________
• Account type: [ ] Checking [ ] Savings
• Routing number (9 digits): ___________________________
• Account number: ___________________________
• Deposit: $ __________ per pay period (remainder to primary)

Attach a voided check or bank-issued direct deposit letter for each account.

Authorization

I authorize [COMPANY NAME] to deposit my pay automatically into the account(s) above, and to debit the account(s) to correct erroneous deposits, as permitted by law. This authorization remains in effect until I revoke it in writing. I understand changes may take one to two pay cycles to take effect.

Employee signature: ___________________________ Date: ______________

---

For payroll use only — Received by: ______________ Date: ______________ Entered: [ ] Yes Effective pay date: __________

---

General template only — not legal advice. Have employment counsel review before use, especially for state-specific requirements. Downloaded from AskHrAI (https://askhrai.com/forms/direct-deposit-authorization).