Health Information Management Team Onboarding Packet

Electronic Direct Deposit of Pay Authorization Form (Page 2 of 2)(Please complete both pages of this form. Keep a copy of this form for your own records)Today’s Date:I authorize my DMC subsidiary and the financialinstitution(s) listed below to deposit fundsautomatically (via electronic transmission) to mychecking and/or savings account(s) each payday. Ialso authorize them to adjust entries in order to correcterrors, as necessary. This authority will remain ineffect until I have canceled it in writing.Your Name (please print):Your Signature:_______________________________________________________________________________________(Name of Financial Institution)_______________________________________________________________________________________(Name of Financial Institution)_______________________________________________________________________________________(City and Stage)_______________________________________________________________________________________(Name of Financial Institution)_______________________________________________________________________________________(City and Stage)Note: The information on this form will replace any previous Electronic Direct Deposit of PayAuthorization Form that you have submitted. Please be sure you have listed all accounts (no more thanthree) into which you would like funds deposited.I:\PAYROLL\Dept. Forms\Direct Deposit (09-11).doc34