Direct Deposit Authorization

Fill out below on your phone or computer, then print or email to Patrick.surrell.dbs@gmail.com

Please print and complete ALL the information below.

Name:

Address:

City, State, Zip:

Refer to the bottom of your personal check to locate the following numbers:

9-Digit Routing Number Account Number (1-17 digits) Check Number (do not include)

Name of Bank:

Account #:

9-Digit Routing #:

Amount:

$ __________ (fixed amount) __________ % (percentage) Entire Paycheck

Type of Account:

Checking Savings

Attach a voided check for each bank account to which funds should be deposited (if necessary).

Employee's Signature

Date

Divine Behavioral Solutions, Inc.