DIRECT DEPOSIT AUTHORIZATION

 

 

Company:       CCMS Government Services, LLC. (CCMS)                                           

 

I.                Action

o New Enrollment  o Change to Enrollment o Termination of Enrollment

 

II.              Employment Information

 

Employee Name (Please Print)                                                                                      

 

Social Security Number              -                       -                      

 

III.            Banking Information

 

Bank Name                                                                   Branch                                     

 

City                                                                  ST                                Zip                              

 

ABA Routing/Transit Number   :⊔⊔⊔⊔-⊔⊔⊔⊔-⊔:

 

Type of Account:           o Checking Account                 o Savings Account

 

Employee’s Account Number:                                                               

 

IV.            Agreement/Authorization

I (We) hereby authorize CCMS, hereafter called Company, to initiate credit entries to my (our) account indicated above and the Financial Organization named above, hereafter called Receiving Bank to credit the same to such account. Charges to said account initiated by Company may only be made to reverse credit amounts erroneously posted. This authorization is to remain in full force and effect until Company has received written notification from me of its termination in such time and in such manner as to afford Company and Bank a reasonable opportunity to act on it.

 

                                                                                                                                               

Employee Signature                                                                Date

 

                                                                                                                                               

Alternate Signature for Joint Account                         Date

 

 

 

***YOU MUST INCLUDE A COPY OF A VOIDED CHECK IN ORDER TO PROCESS***

 

If you are unable to provide a copy of a voided check or a pre-printed deposit ticket with your name and account number on it, we may still process your request upon your acknowledgement that CCMS will not be held responsible for any entry of your banking information based on the information on this form alone.

 

                                                                                                                                               

Employee Waiver                                                                   Date