Direct Deposit Authorization

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EP - DIRECT DEPOSIT FORM

FIRST NAME *

LAST NAME *

Address *

Address

City

State/Province

Zip/Postal

SOCIAL SECURITY NUMBER *

EMAIL FOR EARNING STATEMENT *

NAME OF FINANCIAL INSTITUTION *

FINANCIAL INSTITUTION PHONE NUMBER *

CITY *

STATE *

DO YOU WANT FUNDS SEPARATED INTO 2 ACCOUNTS? *

YES

EXAMPLE $100 INTO SAVINGS AND THE REST INTO CHECKING

TOTAL AMOUNT YOU WANT TO GO INTO THE 2ND ACCOUNT *

ACCOUNT #1 ROUTING NUMBER *

ACCOUNT #1 ACCOUNT NUMBER

ACCOUNT #1 TYPE *

ACCOUNT #2 ROUTING NUMBER *

ACCOUNT #2 ACCOUNT NUMBER

ACCOUNT #2 TYPE *

ATTACH A VOIDED CHECK *

Maximum file size: 104.86MB

If you are human, leave this field blank.