HomeMy WebLinkAboutCOF - Direct DepositEMPLOYEE DIRECT DEPOSIT ENROLLMENT FORM
PLEASE FILL IN COMPLETELY (PRINT OR TYPE)
________________________
______________________________________________________________________________________________________
___________________________________________________________________________________________________________
______________
Empl ID #
Last Name
First
M.I.
IMPORTANT! Please read and sign before submitting.
I hereby authorize the City of Fresno (hereinafter “COF”) to deposit my paycheck to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I
authorize Bank to accept the deposit made by COF to my account. In the event that COF deposits funds erroneously into my account, I authorize COF to reverse the deposit made in error.
This authorization will remain in full force and effect until COF and Bank have received written notice from me of its termination in such time and in such manner as to afford COF and
Bank reasonable opportunity to act on it.
Employee Signature: ___________________________________________ Date: ________________
I authorize the cancellation of all Direct Deposits Contact Phone:
Account Information (Please read instructions fully to ensure your direct deposit is set up correctly.)
You are allowed a maximum 5 direct deposits. Please list them in the order you would like to have them placed into your accounts. The last item must be for the remaining amount owed
to you (check the box labeled “Balance”).
If depositing into a checking account, please attach a voided check (must include your pre-printed name and address).
**Deposit slips will not be accepted under any circumstances.**
If depositing into a savings account, complete and attach a direct deposit sign-up form (available from your financial institution). Form must include the Bank routing number as well
as your account number.
If you are setting up more than one direct deposit please place the corresponding number on the attached voided check or direct deposit sign-up form.
If you already have direct deposits and want to add new ones, make sure you place your current direct deposit(s) on this form as well as the new ones. For current Direct Deposits check
the “No Change” box.
1.
No Change
New
Change
Stop
Bank Name and Branch Location:
Checking
Savings
Deposit Fixed Amount $ per pay period
Deposit Percentage of check % per pay period
Balance of Check
2.
No Change
New
Change
Stop
Bank Name and Branch Location:
Checking
Savings
Deposit Fixed Amount $ per pay period
Deposit Percentage of check % per pay period
Balance of Check
3.
No Change
New
Change
Stop
Bank Name and Branch Location:
Checking
Savings
Deposit Fixed Amount $ per pay period
Deposit Percentage of check % per pay period
Balance of Check
4.
No Change
New
Change
Stop
Bank Name and Branch Location:
Checking
Savings
Deposit Fixed Amount $ per pay period
Deposit Percentage of check % per pay period
Balance of Check
5.
No Change
New
Change
Stop
Bank Name and Branch Location:
Checking
Savings
Deposit Fixed Amount $ per pay period
Deposit Percentage of check % per pay period
Balance of Check