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Direct Deposit Simple Form
Date
Employee Name As It Appears On Bank Account*
Bank Name*
Bank Address*
City*
State, ZIP Code
Routing Number*
Account Number*
Account Type*
Checking Savings Other
AUTHORIZATION OF DIRECT DEPOSIT:

I hereby give permission to the Company to initiate automatic deposits to my account at the financial institution named above. I also authorize the Company to make withdrawals from this account in the event a credit entry is made in error.

I agree not to hold XYZ Co. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my financial institution, or due to an error on the part of my financial institution in depositing funds to my account.

This agreement is to remain in effect until the Company receives a written notice of cancellation from me, or until I submit an updated direct deposit form to Human Resources.
Employee Signature
Attach Voided Check Below