Direct Deposit Form

Direct Deposit Form
Name

First NameLast Name
New (Initial Authorization)Change
Date

MonthDayYear
Date
Bank Information
Type of Account

Checking AccountSavings Account
Name of Financial Institute
Amount (Enter Dollar Amount or Percentage)
Bank Routing Number (9 Digits)
Account Number
Add Additional Banking Information if Multiple Accounts
Type of Account

Checking AccountSavings Account
Name of Financial Institute
Amount (Enter Dollar Amount or Percentage)
Bank Routing Number (9 Digits)
Account Number
Type of Account

Checking AccountSavings Account
Name of Financial Institute
Amount (Enter Dollar Amount or Percentage)
Bank Routing Number (9 Digits)
Account Number
Requirements:

A copy of a voided check or bank issued document confirming the above information should be submitted.

Authorization/Signature

I authorize the Town of Burgaw to initiate credit entries or adjusting entries, either debit or credit, to the above referenced account(s). This authority will remain in effect until I modify or cancel in writing and give proper notice to the Town of Burgaw allowing the Town appropriate time to respond to the request.

Failure to provide correct information may result in returned funds and delayed payroll.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: