LAST NAME

FIRST NAME

INITIAL

EMPLOYEE NO.

Check one below:

_____  New enrollment-Complete the entire form; date, sign and attach a void check.

_____  Change of present financial institution, account and/or amount.  Make appropriate changes, sign, date, and attach a void check.

NOTICE: Direct Deposits are no longer pre-noted. Please verify the information provided is accurate. Incorrect information may delay your deposit.

Section 1:  PRIMARY ACCOUNT   Check one:  ____Checking  or  ____ Savings**

A dollar amount does not need to be specified for this account.  (The primary account will be credited with the balance of net pay remaining after deposits are made to any additional account listed below.)

NAME OF FINANCIAL INSTITUTION________________________________________________________

Transit/ABA No.___ ___ ___ ___ ___ ___ ___ ___ ___ Bank Account No. ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __

Attach a void check.

Section 2:    (Complete this section only if part of the net pay should be deposited into another account.)

ADDITIONAL ACCOUNT      Check one:  ___Checking  or ___Savings** 

A specific dollar amount for the additional account must be designated.  Percentages are not allowable and all remaining net pay will be deposited into the primary account listed above.

NAME OF FINANCIAL INSTITUTION________________________________________________________

Transit/ABA No.___ ___ ___ ___ ___ ___ ___ ___ ___ Bank Account No. ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___                   

Attach a void check.

Amount to be deposited into the additional account:___________________.

Section 3: No fax or copies accepted.  Original signature required.

AUTHORIZATION:  I hereby authorize The School District of Springfield R-12 to initiate credit entries (deposits) and to initiate, if necessary, debit entries (error corrections) for any credit entries made in error to the account(s) listed above. This authorization is to remain in full force until employment is terminated or eligibility is no longer in effect.

DATE:_______________  SIGNATURE:______________________________________

**If all or part of the direct deposit is to a savings account, please write savings on the document that contains bank and account information.