For Office Use Only

MIDDLEBURY COLLEGE

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Payroll Direct Deposit (ACH Credits)

Account Authorization Form

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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.
Employee Name _____________________________________________________________________
(please print)
First
Middle Initial
Last
Middlebury College Employee Identification 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. (If you currently do not have a U.S. bank account, you will have the opportunity to
establish one when you arrive on campus.)
Account:
Routing Number____________________ Account Number _______________________
Depository (or Bank) Name
Depository (or Branch) Location
(City, State, Zip)
Account Type:

SIGNATURE

Checking YOUMUSTATTACHAVOIDEDCHECKFORTHISACCOUNTTOTHISFORM
Savings YOUMUSTATTACHADEPOSITSLIPFORTHISACCOUNTTOTHISFORM

DATE

k:\orgs\sunderland\bonomo\faculty\contracts\2012 contracts\contract enclosures - vt\ls direct deposit form.doc