Direct Deposit Authorization Form
I hereby authorize the Village of Pinehurst and the financial institution(s) shown to deposit my pay directly to my account each payday. If funds to which I am not entitled are deposited into my account, I authorize the Village of Pinehurst to direct the bank to return said funds. This authority will remain in effect until I file a new Authorization form.
Check One:
New
Change
Employee Name: Social Security Number: Account #1
Checking
Savings
Bank Name: Bank Location: Account Number: Routing Number: Deposit Amount
$ or %
Account #2 (Optional)
Checking
Savings
Bank Name: Bank Location:
Account Number: Routing Number: Deposit Amount
$ or %
IMPORTANT: Attach a voided check or deposit slip if this is a checking account.
Employee Signature:
Date:
HR/FS Verification:
Date:
Test Date (employee may receive a check): First Actual Direct Deposit Date:
Human Resources Department 395 Magnolia Rd., Pinehurst, North Carolina 28374 (910) 295-1900 - Fax (910) 295-4434 - www.vopnc.org
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