Instructions

For each checking account(s) attach a voided check

For each savings account(s) attach bank documentation for verification of bank routing and account number(s)

A deposit slip is not acceptable documentation

Provide at least two (2) weeks notice to the Finance Payroll Division prior to changing or closing any account(s)

For one account, complete Section 1 ONLY. For two accounts, complete Section 1 and 2. For 3 accounts, complete Section 1, 2 and 3. Return completed form to the Finance Payroll Division. (Maximum of three accounts.)

DO NOT complete/submit this form if you have entered the payment information in InSITE Employee Self Service

Employee Name: (Last First MI)	Employee Number	Organization
SECTION 1) Deposit Net Pay	Effective Date
Checking Savings	New Change Stop
Name of Financial Institution	Account Type (Select one)	Action Requested (Select one)
Routing Number	Account Number
SECTION 2) Deposit Fixed Amount	$	Effective Date
Checking Savings	New Change Stop
Name of Financial Institution	Account Type (Select one)	Action Requested (Select one)
Routing Number	Account Number
SECTION 3) Deposit Fixed Amount	$	Effective Date
Checking Savings	New Change Stop
Name of Financial Institution	Account Type (Select one)	Action Requested (Select one)
Routing Number	Account Number

I authorize the City and Financial Institution(s) listed above to deposit automatically to the indicated account(s) all amounts payable to me by the City. If funds to which I am not entitled are deposited into my account(s), I authorize the City to direct the Financial Institution to return said funds. This authority shall remain in effect until canceled in writing.

Employee Signature	Date	Daytime Phone Number
For Finance Payroll Office Use Only:	System Input:	Date: