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: ______________

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

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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).