Direct Deposit

Request

  Set up direct deposit               Cancel direct deposit

Employee Name:  _________________________ No.:  _________

Note:  Please attach an original voided check or deposit slip to this request.  Please verify the routing number with your bank.

Name of Bank:  ________________________________  Phone #__________

Address:_____________________City _________State ____ Zip Code______

If requesting a partial direct deposit or a direct deposit into more than one account, please indicate the amount accordingly.

Type of Account(s)    [  ] Checking $ _______             [  ] Savings $__________

Account #(s) :     ___________________                _____________________

Bank Routing #(s): _____________________________________________

By signing below, I authorize the South Texas Lighthouse for the Blind/ Premier Board, Inc. to cancel/direct deposit my payroll check into account(s) noted above.

_________________________________________               _____/_____/_____

Employee Signature                                                            Date