Employee Direct Deposit Authorization Form Template

Employer/Company Name: [Company Name]
Payroll Contact (Optional): [Email/Phone]
Employee Name: [Full Name]
Employee ID (Optional): [ID]
Date: [Date]

1. Authorization

1.1 I authorize [Company Name] to deposit my wages and other payroll payments electronically to the bank account(s) listed below.
1.2 I understand that I am responsible for providing accurate banking information and notifying payroll of changes.

2. Banking Details (Handle Securely)

2.1 Primary Account

• Bank name: [Bank Name]

• Account type: ☐ Checking ☐ Savings

• Routing number: [Routing]

• Account number: [Account No.]

• Last 4 digits (for confirmation): [____]

2.2 Split Deposit (Optional)
☐ No split (deposit 100% to primary account)
☐ Split between two accounts:

• Secondary bank name: [Bank Name]

• Account type: ☐ Checking ☐ Savings

• Routing number: [Routing]

• Account number: [Account No.]

• Deposit method: ☐ Fixed amount $[] per paycheck ☐ []% per paycheck

3. Verification (Recommended)

3.1 Provide one of the following (recommended):
☐ Voided check
☐ Bank letter/statement showing routing/account (redact balances)
☐ Payroll system micro-deposit verification (if available)
☐ Other: [Method]

4. Changes and Cancellation

4.1 Any changes to banking information must be submitted in writing using an updated form.
4.2 Changes must be received at least [__] business days before payroll processing to take effect.
4.3 I may revoke this authorization by providing written notice, subject to payroll processing timelines.

5. Data Handling (Optional)

5.1 Banking information will be used only for payroll purposes, stored securely, and access will be limited to authorized personnel.

Signatures

Employee: [Full Name]
Date: [Date]
Signature: ___________________________

Payroll/HR Representative (Optional): [Name]
Date: [Date]
Signature: ___________________________