CHECKW'SE — PAYROLL—— DIRECT DEPOSIT ENROLLMENT / CHANGE FORM Employee Name: Movant foc SSN: XXX-XX-ZAU | COMPLETE THE INFORMATION BELOW TO ENROLL OF CHANGE ENROLLMENT IN DIRECT DEPOSIT Bank Name Account # ‘Account Type Twish to deposit: > [EJ Remainder of Net Pay | | g3d 2274 B\BT Ef crecring [\O0__ % of Net Bane of Amenca 1 savings [C2 specie amounts 7 remove from Direct Deposit [E Remainder of Net Pay DD checking ae | A sivings | sveciicamounes TD Remove from Direct Deposit L ATTACH ONE OF THE FOLLOWING FOR EACH ACCOUNT INDICATED ABOVE. [1 voided copy ofa check [A sank letter or specification Sheet signed by a bank representative EMPLOYEE AUTHORIZATION STATEMENT hereby authorize my employer to deposit my wages into the bank account(s) indicated on this form and initiate (ifnecessary) debit entries or adjustments for any credit entries in error to my account. | attest that the associated transactions authorized under this agreement will not be international ACH transactions (IAT). 1ATs shall include credit or debit entries involving a financial agency (an entity authorized to accept deposits transfer funds, or issue money orders), ifthe office of financial agency that is involved in the payment transaction (holding accounts that are debited or credited, receiving or making payments or serving as an intermediary in any part of the transaction) is outside of the US. EMPLOYEE SIGNATURE: Hest Aa pare: le [Lo] 23 a COMPANY APPROVAL COMPANY NAME:, DATE: COMPANY SIGNATUREBANK OF AMERICA TANK OF AMERICA.N A (THE BANK") Non-Federal Direct Deposit Enrollment Request Form ‘Authorization agreement for automatic deposits (ACH credits) Directions for Customer Usi 1) Ensure entire form is complete, then sign and date state where your account was opened + Use the ABA routing number om 2) Ensure appropriate Employer/ Company address Is ‘used when mailing completed form form tor completeness and suitably. Employer 3) Employer Company shout review this sorcery pore oe yecount type, number and ABA routing number below to Company prefers or requires ther own form, use a help complete their form 44) Mailform directly te Employer / Company (Noe: It's not necessary for employer or company to return the form to the bark once rect depeat i setup into te payroll syst) Employer / Company Name: State Zip Employer Address City inate credit enties to my Bank of America Checking (wo) authors the above named Employer Company tule Sans sess dctedbebwand to creat tw samo sch account| We) acinowfadg at he {tpnason ofthe ACH tansacons tomy or account must comp) wa he rovsons of US a Note: Funds can be deposited into one account or spit between accounts a5 set percent or dollar mount. ‘Account Type 7] Checking F] Savings State Acct Opened NY Account Number _-_4830.7279 8187 = ‘ABA Routing Number 021000! ease Deposit Amount % OR $ (Fiat Amount) “’—— VOID ‘Tel Banket America monies to which Lam not ented are deposited to my account. | authorize the Employer / Company (issuer to {iret ne france insttuton fortum said funds and | authorize the financial nsititon to act onthe Employer / Company dresion ad to ret said fund. TMs authoiy wil remain in effet unil Employer / Company has ‘ecoved writen noticaton Irom me of ts termination in such time and in such manner as to affrd Employer / ‘Company and france inetion a reasonable epportnity to act on MORGAN TFORD Trae 89 SHELDON DR MECHANICVILLE NY 121180000, ares Ciyisttea cion2023 SUS.381.0598 a Telephone Number Signin Foe) NOTE: writen credit authorization must provide thatthe ecsver may revoke the authorization ony by notin the originator n the manner specied inte authorization. : 00.14-9291m 00202-2014