Fill and Sign the Direct Deposit Form Automatic Debit and Credit Agreement

DIRECT DEPOSIT AGREEMENT I hereby authorize on this ____ day of _______________, 20______, ___________________________________(Employer) to initiate electronic debit and or credit entries to the bank account shown below for an allotted amount. I understand that adjustment entries may be made to this account to insure an accurate and balanced accounting (debits and credits must balance) of all transactions. This authorization will remain in effect until; 1. I notify my Bank and Employer in writing to terminate this agreement and give the Bank and Employer reasonable time to so terminate the agreement, or 2. The Bank and/or the Employer have sent me five (5) business days advance written notice of the Banks and/or Employers termination of this Agreement. I understand that any cancellation in writing will become effective no earlier than 5 business days after the day the last transaction has cleared and there are no outstanding balances to the account. ___________________________________ __________________________ FINANCIAL INSTITUTION BRANCH ___________________________________ __________________________ CITY & STATE PHONE NUMBER ____________________________________ __________________________ PLEASE PRINT YOUR NAME DATE Account Information ___________________________ ___________________________________ ROUTING (ABA) NUMBER ACCOUNT NUMBER AT FINANCIAL INSTITUTION checking / savings (Please Circle) Direct Deposit Amount $______________________ (per pay period) Your Signature: _______________________ Social Security Number: _______________________ Attached to this authorization is a voided personal check for veri