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HRIS Payroll Services

Direct Deposit Authorization Form

Last Name: ___________________________ First Name: _________________________ M._____

Banner ID:___________________ Phone Number:_________________________


I authorize my employer, Albert Einstein College of Medicine, Inc, to deposit my net salary into the account(s)
indicated below.

To ensure that my account(s) is/are properly credited, I have attached a voided check from the checking
account(s), or a deposit slip from the savings account(s) where I have requested my net salary to be
deposited.

I agree that this authorization will remain in effect until I provide written notification to Albert Einstein
College of Medicine, Inc terminating this service.

Please indicate your payroll frequency: ( ) Semi-monthly ( ) Bi-Weekly

___________________________________ __________________
Signature Date

You may list up to three accounts below, including the Credit Union

Bank Name: Bank Name: Bank Name:

____________________ ____________________ ____________________

Bank address:________ Bank address:________ Bank address:________

____________________ ____________________ ____________________

Title of Account: Title of Account: Title of Account:

____________________ ____________________ ____________________

O Checking O Saving Acct O Checking O Saving Acct O Checking O Saving Acct

Bank Routing Number: Bank Routing Number: Bank Routing Number:

____________________ ____________________ ____________________

Bank Account Number: Bank Account Number: Bank Account Number:

____________________ ____________________ ____________________

____% to be deposited _____% to be deposited _____% to be deposited

Percentages must add up to 100%

Please note: You will receive your next payment in the


For Payroll use only: form of a physical check by mail while your new account
Input by (Init):______ Date:______ information goes through a verification process.

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