I, (Name of Employee), hereby authorize (Name of Employer) to deposit the sum of (Specify) Dollars ($_____) from my regular paycheck into (Name of Bank), account number (Specify).

I understand that my consent can be withdrawn at any time, provided it is done so in writing.

_______________________________
Signature of Employee

_______________________________
Print Name of Employee

Social Security No.:

Date:

Approved By:

Date: