| AUTOMATED PAYROLL SOLUTIONS, LLC P.O. BOX 702 SIKESTON, MO. 63801 573-471-1983 |
Direct Deposit / Authorized Accounts
Employer: ____________________________________________________
Employee Name: _______________________________________________
Social Security Number: ________ - ______ - ________
Financial Institution #1 Checking Savings
Full deposit Percent ______% Specific amount each check date $_________
Bank Name __________________________________________
Bank Address __________________________________________
Bank City, State, Zip __________________________________________
Routing & Transit No. __________________________
Account No. __________________________
Financial Institution #2 Checking Savings
Full deposit Percent ______% Specific amount each check date $_________
Bank Name __________________________________________
Bank Address __________________________________________
Bank City, State, Zip __________________________________________
Routing & Transit No. ___________________________
Account No. ___________________________
Please attach a copy of a voided check for each checking account.
I/We authorize Automated Payroll Solutions, LLC, and the Financial Institution(s) listed above to initiate deposits of funds to which I am
entitled automatically to the above listed account(s). If funds to which I am not entitled are deposited to my account(s), I authorize you to
initiate debit entries and adjustments to return said funds. This authority shall remain in effect until I have cancelled it in writing at such
time and in such manner as to afford you a reasonable opportunity to act.
Signature _____________________________________ Date ________________
Employer: ____________________________________________________
Employee Name: _______________________________________________
Social Security Number: ________ - ______ - ________
Financial Institution #1 Checking Savings
Full deposit Percent ______% Specific amount each check date $_________
Bank Name __________________________________________
Bank Address __________________________________________
Bank City, State, Zip __________________________________________
Routing & Transit No. __________________________
Account No. __________________________
Financial Institution #2 Checking Savings
Full deposit Percent ______% Specific amount each check date $_________
Bank Name __________________________________________
Bank Address __________________________________________
Bank City, State, Zip __________________________________________
Routing & Transit No. ___________________________
Account No. ___________________________
Please attach a copy of a voided check for each checking account.
I/We authorize Automated Payroll Solutions, LLC, and the Financial Institution(s) listed above to initiate deposits of funds to which I am
entitled automatically to the above listed account(s). If funds to which I am not entitled are deposited to my account(s), I authorize you to
initiate debit entries and adjustments to return said funds. This authority shall remain in effect until I have cancelled it in writing at such
time and in such manner as to afford you a reasonable opportunity to act.
Signature _____________________________________ Date ________________
