Download authorization agreement - Hillsboro City Schools

AUTHORIZATION AGREEMENT
FOR DIRECT DEPOSIT PAYROLL
I hereby authorize the HILLSBORO CITY SCHOOL DISTRICT hereinafter called DISTRICT, to initiate
electronic entries in my:
FINANCIAL INSTITUTION NAME _________________________________________________________
ROUTING/TRANSIT NUMBER ____________________________________________________________
(ACH Number of the Financial Institution)
THE PAYROLL SYSTEM WILL PROCESS THE FIXED AMOUNTS FIRST. ANY REMAINING BALANCE WILL BE PROCESSED AS
A PERCENTAGE. THE PERCENTAGE TOTAL MUST EQUAL 100 PERCENT.
Checking ACCT #___________________________ Dollar Amount ________________Fixed
_____________________Percent
Checking ACCT #___________________________ Dollar Amount ________________Fixed
_____________________Percent
Savings ACCT #___________________________ Dollar Amount _________________Fixed
______________________Percent
Savings ACCT #___________________________ Dollar Amount _________________Fixed
______________________Percent
This authority is to remain in full force and effect until the DISTRICT has received written notification
from me of its termination in such time and in such manner as to afford the DISTRICT and FINANCIAL
INSTITUTION a reasonable opportunity to act on it.
NAME ____________________________________
SSN __________ ________ ____________
SIGNATURE _______________________________
DATE ________________________________
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PLEASE SEND MY DIRECT DEPOSIT NOTIFICATION AS FOLLOWS:
_____E-MAIL NOTIFICATION ADDRESS___________________________________________________
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TO BE COMPLETED BY THE EMPLOYEE’S BANK OR DEPOSITORY INSTITUTION
I certify that the above routing/transit number and account number are valid, and we are an ACH member.
NAME _________________________________
PHONE (_______) _________ - _____________
TITLE__________________________________
INSTITUTION_____________________________