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)

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download