DIRECT DEPOSIT AUTHORIZATION

Full Legal Name:                     ______________________________________

Identification Number:              ______________________________________

Social Security Number:          ______________________________________

Bank Name/Branch:                ______________________________________

Account Number:                    ______________________________________

Check the appropriate item:

_____   Direct deposit.

The undersigned hereby requests and authorizes the entire amount of my paycheck each pay period to be deposited directly into the bank account named above.

_____   Direct payroll deduction deposit.

The undersigned hereby requests and authorizes the sum of ___________________________________________ dollars ($___________ ) be deducted from my paycheck each pay period and to be deposited directly into the bank account named above.

_____   I would like to cancel my deposit authorization.

The undersigned hereby cancels the authorization for direct deposit or payroll deduction deposited previously submitted.

____________________________________                           ______________

Employee Signature                                                             Date

(Please attach a copy of deposit slip.)
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