Account Deposit

Direct Deposit Acknowledgment Form

Company Name

Name ID Number

Account Information

Checking Savings

Deposit in:

% of Net

Routing / Transit Number

$ Dollar Amount Remainder of Pay

Account Number

Bank Name

I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named account. I agree, and it is my intent, to sign this document electronically, and that signing and submitting this document electronically is the legal equivalent of having placed my handwritten signature on it. Signature

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