Fill and Sign the Direct Deposit Form Oregongov

DIRECT DEPOSIT AUTHORIZATION OR CANCELLATION Full Legal Name: ______________________________________ Identification Number: ______________________________________ Social Security Number: ______________________________________ Bank Name/Branch: ______________________________________ Transit/Routing/ABA# ______________________________________Account Number: ______________________________________ This is a (check one): Checking Account Savings Account Check the appropriate item: Direct Deposit. The undersigned hereby requests and authorizes the entire amount of my paycheck each pay period to be deposited directly into the bank account named above. Direct payroll deduction deposit. The undersigned hereby requests and authorizes the sum of __________________dollars ($_________) be deducted from my paycheck each pay period and to be deposited directly into the bank account named above. I would like to cancel my deposit authorization. The undersigned hereby cancels the authorization for direct deposit or payroll deduction deposited previously submitted. ____________________________________ _________ Employee Signature Date NOTE: Please return this authorization along with a VOIDED CHECK on your account to: Company Name