Human Resources, Inc. & Subsidiaries
Including Human Resources International, Inc., HR Specialists, Inc., Human Resources Management, Inc.
and Design HR, Inc. hereinafter referred to as “HRI”
DIRECT DEPOSIT AUTHORIZATION
Worksite Employer
Last Name
First Name
MI
Social Security #
I hereby authorize HRI to initiate credit entries or such adjusting entries, either debit or credit, which are necessary for
corrections, to my account(s) indicated below and the depository(ies) named below to credit (or debit) the same such account.
Deposit Account 1 (Please attach a voided check or withdrawal slip)
Institution Name
Type of account
City
State
ABA Routing Transit # (9 digits)
Account #
Specify one
$$ Amount
$
Add
Checking
%
Deposit Account 2 (Please attach a voided check or withdrawal slip)
Type of account
City
State
ABA Routing Transit # (9 digits)
Account #
Specify one
$$ Amount
$
Add
City
State
ABA Routing Transit # (9 digits)
Account #
Specify one
$$ Amount
$
Savings
Zip Code
%
Deposit Account 3 (Please attach a voided check or withdrawal slip)
Type of account
Delete
Checking
% of paycheck
Institution Name
Savings
Zip Code
% of paycheck
Institution Name
Delete
Add
Delete
Checking
Savings
Zip Code
% of paycheck
%
Employee Authorization
This authority is to remain in full force and effect until HRI has received written notification from me of its termination in
such time and in such manner as to afford HRI reasonable opportunity to act on it. There will be approximately two (2)
weeks of pre-noting (live checks) until direct deposit is initiated.
Employee Signature: _______________________________________________ Date: _____/____/_____
HRI use
Input
Reviewed