Company Name__________________________________________________________________

Employee Name__________________________________________________________________

I authorize ______________________________________to initiate credit entries or debit

corrections to my_____Checking _____ Savings account indicated below and the depository

named below.

Depository Name_________________________________________________________________

Checking Account #______________________________________________________________

Deposit Amount $________________________________ or Net Pay ______________________

Savings Account # _______________________________________________________________

Deposit Amount $ ________________________________ or Net Pay _____________________

Signature__________________________________________Date________________________