West Islip UFSD

Authorization Agreement for Direct Deposit

First name *

Last name *

Department: *

Enter A Valid Email Address Below: * 🛈

* 🛈

Date of Request: * +

Authorization

I authorize my employer to deposit my net pay directly into my account {select one below) and to initiate (if necessary) debit entries and adjustments for any credit entries in error to my account. *

Checking

Savings

I agree that this authorization will remain in effect until I provide written notification to the Payroll Department at West Islip Public Schools terminating this service. *

Yes

No

Signature *

clear

Bank information

Name on Your Account: *

Social Security Number: *

Name of financial institution: *

Address of financial institution: *

Routing number: *

Account number: *

To ensure that my account is properly credited, please upload a voided check or a Direct Deposit Set-up Form provided by the bank: *

Amount to be deposited to this account: *

100% of my net pay

Other Other

Are there any special instructions or anything you would like to add?