For Office Use Only

MIDDLEBURY COLLEGE
Payroll Direct Deposit (ACH Credits)
Account Authorization Form
I hereby authorize Middlebury College to initiate credit entries to the account indicated below and the depository
financial institution named below to credit the same to such account. I acknowledge that the origination of ACH
transactions to my account must comply with the provisions of U.S. law.

Name T.'
print)

Employee
(please

i t-:-

First

Middle lnitial

Middlebury College Employee ldentification Number

Please NOTE: You must establish a U.S. bank account prior to signing up for direct deposit; we do not directly
deposit pay into international bank accounts.. Please be sure to provide accurate banking information to ensure
successful deposit of your pay. (lf you currently do not have a U.S. bank account, you will have the opportunity to
establish one when you anive on campus.)

Account:

RoutingNumbe

t'lu

AccountNumber

3r''c c"l t'l

,-

ll?-

Depository (or Bank) Name

Depository (or Branch) Location
Account

-/-

(City, State, Zip)

A vorDED cHEcK FoR THrs AccouNT To rlrrs FoRM
A DEposrr slrp FoR THrs AccouNT To rHrs FoRM

Type: ElCnecring - you MUsr ATTACH

E Savings - you MUSTATTAcH

.Ioe C\lsfoner
T234 Main Sh'eet
Anytown. US 123,t5

1007

2t

Pay to

The order of:

DOLLARS

Routing

Nnmler

SIGNATURE

Accouut lfurnber

DATE

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