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Complete this form, then print it, sign it and take it to your employer's payroll department to request direct deposit of your paycheck. The form is needed by .

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Authorization agreement for automatic deposits (ach credits). This document must be signed by employees requesting automatic deposit of paychecks and retained on file by the employer.

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I hereby authorize {enter company name} to directly deposit my pay in the bank account(s) listed below in the percentages . We are vaccinating all eligible patients.

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