C:\TMCC\NPS PROJECT\Client Forms\Direct Deposit Agreement-employee.doc
Employee Direct Deposit Agreement
Employee Name ____________________________ Employee SSN _____________
Employer Name ____________________________ Date _____________
Account #1:
___ New Account ___ Change Account ___ Delete Account
___ Checking Account ___ Savings Account
Bank Name ______________________ Flat $___________
Routing Number ______________________ Percentage ___________%
Account Number ______________________
Account #2:
___ New Account ___ Change Account ___ Delete Account
___ Checking Account ___ Savings Account
Bank Name ______________________ Flat $___________
Routing Number ______________________ Percentage ___________%
Account Number ______________________
Account #3:
___ New Account ___ Change Account ___ Delete Account
___ Checking Account ___ Savings Account
Bank Name ______________________ Flat $___________
Routing Number ______________________ Percentage ___________%
Account Number ______________________
Account #4:
___ New Account ___ Change Account ___ Delete Account
___ Checking Account ___ Savings Account
Bank Name ______________________ Flat $___________
Routing Number ______________________ Percentage ___________%
Account Number ______________________
Note – Any check net remaining after dispersing through the above accounts will be cut with an actual
check. Please provide a voided check for each account above. A deposit slip will not work.
I herby authorize the above listed “Employer” and its payroll processor, Nevada Payroll Services, LLC, to
deposit any amounts owed me by initiating credit entries to my account at the financial institutions indicated
above. Further, I authorize the Financial Institution to accept any debit entries indicated by “Employer” or
Nevada Payroll Services, LLC for erroneous or unfunded amounts previously credited. I authorized my
“Employer” or Nevada Payroll Services to debit my account for an amount not to exceed the original amount
of the erroneous credit.
This Authority is to remain in full force and effective until “Employer” has received written notification from
me of its termination in such time and in such manner as to afford “Employer” reasonable opportunity to act.
_________________________________ _______________
Signature Date
Nevada Payroll Services, LLC
“A Payroll and Automation Services Company”
