Direct Deposit Authorization
How direct deposit works:
On payday you will receive a paystub showing your gross salary, taxes, other deductions, and
net pay. Your money will already have been deposited into your account. The amount of the
deposit will appear on your bank statement.
Form instructions:
1. Circle the type of account to indicate whether your pay will be deposited
into your checking or savings account.
2. Fill in all other information as indicated.
3. Attach a voided check (for checking accounts) or a deposit slip (for
savings accounts) for verification of all financial institution information.
4. Please be sure to sign and print your name at the bottom of the form.
5. Keep a copy of authorization form for your records.
EMPLOYEE’S AUTHORIZATION
AUTHORIZATION FOR DIRECT DEPOSIT
I authorize Bethel Township, Clark County to initiate electronic credit entries, and if necessary,
debit entries and adjustments for any credit entries in error to my:
Checking Account Savings Account
(please circle one)
each pay period. I acknowledge that the origination of ACH transactions to my account must
comply with the provisions of U.S. law.
Date: ________________________
Staple
Voided
Check
or
Deposit
Slip
Here
Financial Institution Name: ____________________________________________
Account Number: ___________________________________________________
Routing/Transit Number: _____________________________________________
Financial Institution City & State: _______________________________________
Signature: __________________________________________________
Print Name: _________________________________________________