Blinn College
Direct Deposit Authorization Form
Check One: Full-time Part-time Student Worker
Printed Name __________________________________ Blinn ID Number _________________
New Agreement Account Change Please attach a voided check
For multiple accounts, indicate the priority order in which they should be processed. The “smaller” amount should be priority 1 and will be deposited first, with the higher percentages placed last. (See example on next page)
PRIORITY : 1 2 3
NAME OF BANK ________________________________
TRANSIT/ROUTING NO. ____________________________________
ACCOUNT NUMBER _____________________________________
PERCENTAGE __________________% OR AMOUNT $ ________________
ACCOUNT TYPE Checking Savings (check only one)
PRIORITY : 1 2 3
NAME OF BANK ________________________________
TRANSIT/ROUTING NO. ____________________________________
ACCOUNT NUMBER _____________________________________
PERCENTAGE __________________% OR AMOUNT $ ________________
ACCOUNT TYPE Checking Savings (check only one)
PRIORITY : 1 2 3
NAME OF BANK ________________________________
TRANSIT/ROUTING NO. ____________________________________
ACCOUNT NUMBER _____________________________________
PERCENTAGE __________________% OR AMOUNT $ ________________
ACCOUNT TYPE Checking Savings (check only one)
I hereby authorize Blinn College to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account listed below. This authority is to remain in effect until Blinn College has received written notification from me of its termination in a timely and in a manner that affords Blinn College and Depository a reasonable opportunity to act on it.
Will these payments be forwarded to a financial institution outside the United States? Yes No
SIGNED __________________________________ DATE __________________
Direct Deposit Authorization Form
SAMPLE FORM
This example shows an employee who will deposit $100.00 from each paycheck to his savings account, and the remainder to his checking account.
Check One: Full-time Part-time Student Worker
Printed Name __Sample Employee________________________ Blinn ID Number _B00123456_______
New Agreement Account Change Please attach a voided check
For multiple accounts, indicate the priority order in which they should be processed. The “smaller” amount should be priority 1 and will be deposited first, with the higher percentages placed last.
PRIORITY : 1 2 3
NAME OF BANK ____Sample Bank____________________________
TRANSIT/ROUTING NO. __Sample Routing Number__________________________________
ACCOUNT NUMBER _____Sample Account Number 1________________________________
PERCENTAGE __________________% OR AMOUNT $ _____100.00___________
ACCOUNT TYPE Checking Savings (check only one)
PRIORITY : 1 2 3
NAME OF BANK ___Sample Bank_____________________________
TRANSIT/ROUTING NO. ___Sample Routing Number_________________________________
ACCOUNT NUMBER ______Sample Account Number 2_______________________________
PERCENTAGE _____100__________% OR AMOUNT $ ________________
ACCOUNT TYPE Checking Savings (check only one)
PRIORITY : 1 2 3
NAME OF BANK ________________________________
TRANSIT/ROUTING NO. ____________________________________
ACCOUNT NUMBER _____________________________________
PERCENTAGE __________________% OR AMOUNT $ ________________
ACCOUNT TYPE Checking Savings (check only one)
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