Direct Deposit Initiation/Change Form Achievement Matters, Inc.

This form is to be used for employees of Achievement Matters, Inc. and/or AAVANTE, Inc. that choose to utilize the Direct Deposit program offered. Instructions: 1. Complete the REQUIRED INFORMATION section (Please print legibly). 2. Complete the BANKING INFORMATION section to specify where your wages are deposited. 3. Sign the bottom of the form. 4. Retain a copy of this form. Return the original to Achievement Matters, Inc. 5. Submit a copy of your voided check. Direct Deposit will not be processed until a voided check or a form from your Banking Institution is received. REQUIRED INFORMATION Name: ____________________________________________________ (Check One)

W-2 Employee 1099 Contractor

New/Additional Account Cancel Direct Deposit

BANKING INFORMATION

Change Account

I Decline Direct Deposit (please mail me a check)

I would like my wages deposited to the following bank account: Checking/Savings

(Check One ONLY)

Name of Bank

Amount/Percent or All

Bank Routing Number

Account Number

Please note: It is your responsibility to verify deposits on a per-period basis before writing checks against these funds.

Achievement Matters, Inc. is not responsible for bank errors, fees, or delays in funds availability due to banking policies.

Signature:

Date:

Please include a voided check(s) along with this form Please note: It is your responsibility to ensure that Achievement Matters, Inc. has your most current banking information. If you list an account number that is incorrect or closed, Achievement Matters reserves the right to charge $10.00 for any returned payments.

Revised: January 1, 2013