DIRECT DEPOSIT REQUEST FORM
DIRECT DEPOSIT REQUEST FORM
• Funds are available to you on payday.
• Eliminates chance of lost or stolen checks.
• Eliminates trip to the bank and waiting in line.
RETURN TO: DIRECTOR OF PAYROLLS – H-DH3-05
NAME: ______________________________________________
SOCIAL SECURITY # (last 4 digits only) __________________
EMPLOYEE/STUDENT ID # ____________________________
DEPARTMENT: ______________________________________
MAIL CODE/LOCATION: ______________________________
PHONE NUMBER _____________________________________
You may have your net pay or a portion of your pay deposited into your existing account.
Please check your selection.
___ CHECKING ____FULL DEPOSIT ____PARTIAL $________
___ SAVINGS ____FULL DEPOSIT ____PARTIAL $________
NAME OF BANK: _____________________________________
ROUTING #: __________________________________________
ACCOUNT #:__________________________________________
** NOTE: You must attach a copy of your personal check for verification of your
bank and account number for deposit to a checking account. This verification may take two (2) pay periods before direct deposit is in effect.
PLEASE VOID CHECK
___________________________________ ______________
SIGNATURE DATE
................
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