Direct Deposit Enrollment Form

I hereby authorize my employer*

to initiate credit entries and to initiate if necessary, debit entries and adjustments for any credit entries in error to my (our) account or accounts listed.

Employee Name*

Employee Number

Bank 1

Bank Name*

Percent*

Flat Amount*

Routing Number*

Account Number*

Bank 2

Bank Name

Percent*

Flat Amount*

Routing Number

Account Number

Bank 3

Bank Name

Percent

Flat Amount

Routing Number

Account Number

Electronic Funds Transfer (15 U.S.C. § 1693): I hereby acknowledge receipt of notice from my Bank of my responsibilities under the Electronic Funds Transfer Act (“Act”), my potential liability for certain unauthorized electronic fund transfers, my duty to promptly report unauthorized transfers, any charges for electronic fund transfers, if applicable, the right to stop payment of pre-authorized electronic fund transfers, the procedure to initiate such stop payment orders, my right to receive documentation of electronic fund transfers, and the Bank’s liability pursuant to the Act.

Limitation of Action: I acknowledge that I will have 60 days from the date of a withdrawal or deposit to my Bank account to dispute the withdrawal or deposit. I furtheracknowledge that I shall dispute a withdrawal or deposit by providing the Company/Employer and IC with written notification of any discrepancies, errors or disputes concerning any transfer of funds to or from any account processed by IC. I acknowledge that all written notices must include the following information:

The name of the Company/Employer authorized to make the transaction;
The federal taxpayer ID number of the Company/Employer;
My full name;
My contact information;
The name, account number and ABA number of the transaction in question;
The dollar amount of the transaction in question; and
A description and explanation of the error.

I acknowledge that, if possible, the Company/Employer , its agent, or IC will inform me of the results of their investigation into the disputed transaction within ten (10) days of the receipt of my complaint, and will attempt to correct any identified error promptly. However, if my employer, its agent, and/or IC need additional time, I understand that they may take up to 45 days to investigate my complaint. For transfers initiated outside the United States or transfers resulting from point of sale or debit/access cards, I understand that the time periods for investigating and resolving errors will be 45/90 days, respectively.

Upon signing your name electronically on this Direct Deposit Enrollment form, you are agreeing that your electronic signature is the legal equivalent of your handwritten signature.