Direct Deposit Authorization Form

Collects employee bank details and authorization to set up direct deposit, including account verification and optional split deposit instructions.

Employee Information

• Full Name
• Employee ID
• Work Email
• Department

Bank Account Details

• Account Holder Name
• Bank Name
• Account Type
• Routing Number
• Account Number (last 4 digits)
  For security and data minimization, enter only the last 4 digits of the account number.
• Deposit Type

Split Deposit Instructions

• How should the deposit be split?
• Split Percentage
  Enter the percentage of each paycheck to deposit into this account.
• Split Amount
  Enter the fixed amount to deposit into this account each pay period.
• Where should the remaining balance go?

Verification and Authorization

• Verification Document
  Optional: upload a voided check or bank letter if your payroll team requires verification.
• I authorize my employer to deposit my net pay into the bank account(s) provided above and, if necessary, to reverse any erroneous deposits made in error.
• I consent to the collection and processing of my PII and banking information for payroll administration and verification purposes.
• Electronic Signature
• Date