Direct Deposit Agreement Form/
Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize the City of Schertz to initiate automatic deposits to my account at the financial institution named below.
I also authorize the City of Schertz to make withdrawals from this account in the event that a credit entry is made in error.
Further, I agree not to hold the City of Schertz responsible
for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in
depositing funds to my account.
This agreement will remain in effect until the City of Schertz receives a written notice of cancellation from me or my financial institution, or until
I submit a new direct deposit form to the Payroll Department.
Employee Name (please type or print legibly)
SSN (last 4 digits only)
Note: You must stop a current account set
for remaining net deposit before another one can be created.
Account Information (type or print legibly)
Action Requested
Name of Financial Institution
Savings ☐ Checking
☐
New ☐ Change to existing ☐ Stop ☐
100% net ☐ Set $ amount
Routing Number (9 digits) Account Number Primary account holder name and signature if
different from employeePrinted Name
Signature
DateAccount Information (type or print legibly) Action
Requested
Name of Financial Institution Savings ☐ Checking ☐
New ☐ Change to existing ☐ Stop ☐
100% net ☐ Set $ amount
Routing Number (9 digits)
Account Number Primary account holder name and signature if different from employeePrinted NameSignatureDate Employee Signature
Employee Signature Date:
Please
attach a voided check or deposit slip and return this form to the Payroll/Finance Department. Allow one payroll period for activation of new accounts. If you receive your payroll via
direct deposit at a US bank and then have the entire payroll amount forwarded to a bank in another country, please advise the Finance Department. There are formatting requirements for
these transactions that need to be followed. It will not affect your payroll.
COS-DDForm-Revised 08/26/2016