Western Dubuque County Community School District
Direct Deposit Payroll Authorization
2/17/2019
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DIRECT DEPOSIT PAYROLL AUTHORIZATION

 

I hereby authorize Western Dubuque Schools and the depository named below, to initiate credit entries and to initiate, if necessary, debit adjustments for any credit entries in error to my account as listed below. Deposits can be made into one account or multiple accounts at one depository or multiple depositories.

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Description (Provide a brief description if this is a change of a previous deposit. For example: Increase from a $100 deposit to account #123456 to $200 deposit to the same account; Change from Bank A to Bank B, etc.)
Account #1
Depository (Bank or Credit Union) Name: *
Routing # (Transit/ABA #): *
Account #: *
                .
*
Amount to Deposit

Other Amount $
*
Type of Account

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Account #2 (if desired) 
Depository (Bank or Credit Union) Name:
Routing # (Transit/ABA #):
Account #:
                .

Amount to Deposit

Other Amount $

Type of Account

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Account #3 (if desired) 
Depository (Bank or Credit Union) Name:
Routing # (Transit/ABA #):
Account #:
                .

Amount to Deposit

Other Amount $

Type of Account

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Please Attach a Copy of a Check

Click to Upload Files

OR Mail a Voided Check to:  Attention: Payroll/Direct Deposit;  Western Dubuque Schools; 310 4th St SW, PO Box 68; Farley, IA 52046-0068

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This authority is to remain in full force until Western Dubuque Schools has received written notification from me of its termination in such time & in such manner as to afford Western Dubuque Schools a reasonable opportunity to act on it.

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Name: *
Address: *
City, State, ZIP
City, State, ZIP: *
Date:
(mm/dd/yyyy)

For Company Use Only

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Date Received:
(mm/dd/yyyy)
Processed By:

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Routing Instructions
Please route this form to the following personnel:
1. Payroll
Complete the information below to route your form. * Indicates Required Fields
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.