MORAVIAN CHURCH IN AMERICA, SOUTHERN PROVINCE
PROVINCIAL TREASURER’S OFFICE
459 SOUTH CHURCH ST
WINSTON-SALEM, NC 27101
DIRECT-DEPOSIT SIGN-UP FORM
Name of Payee (last,first,middle initial) _______________________________________
Address ________________________________________________________________
City ___________________________State_________________Zip Code____________
Social Security Number ___ __ ___
Employment Location(Church, Daycare or Agency)______________________________
Type of Depositor Account/Amount:
Checking Depositor Account Number:
Savings Depositor Account Number:
Checking ____________
Savings ____________
__ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __
PAYEE CERTIFICATION:
I certify that I am entitled to the payment identified above. I authorize my payment to be
sent to the financial institution named below to be deposited and any adjustments made to the
designated account. I can terminate the direct deposit of this payroll arrangement simply by
giving written notice.
SIGNATURE___________________________ DATE________________
Name and Address of Financial Institution:
Name_______________________________
Address_____________________________
______________________________
______________________________
.
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(HAVE YOUR BANK FILL IN THE INFORMATION BELOW)
Or: Send back to the Treasurer’s Office with this form a blank void check, savings deposit slip or
both if the monies are being split between a checking and savings account
Routing Number Checking: __ __ __ __ __ __ __ __ __
Routing Number Savings: __ __ __ __ __ __ __ __ __
I confirm the identity of the above-named payee and the account number. As representative of
the above-named financial institution, I certify that the financial institution agrees to receive and
deposit the payment identified.
Signature of Representative__________________________ Date_____________
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