EMPLOYEE DIRECT DEPOSIT AUTHORIZATION AGREEMENT

Employee #: Name:
(Please print)

I authorize you and the financial institution(s) listed below to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my checking/savings account(s) each payday. This authority will remain in effect until I have cancelled it in writing. Signature Date:

1st Financial Institution:

Bank Name: Branch Address: Account Type:
(Choose One)

Checking Savings

(Please attach a voided check)

Deposit Amount:(Choose One)

Amount: $ Net Check

TRANSIT ROUTING NUMBER: ACCOUNT NUMBER:

2nd Financial Institution:

Bank Name: Branch Address: Account Type:
(Choose One)

Checking Savings

(Please attach a voided check)

Deposit Amount:(Choose One)

Amount: $ Net Check

TRANSIT ROUTING NUMBER: ACCOUNT NUMBER:

Revised5/4/2011