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DIRECT DEPOSIT AUTHORIZATION

Please print and complete ALL the information below.

Name:*

Address:

City, State, Zip:

Name of Bank:*

Account #:*

9-Digit Routing #:*

Type of Account:*

Checking

Savings

Attach a voided check for each bank account to which funds should be deposited (if necessary)

Max. file size: 512 MB.

Employee’s Signature:*

Date:*

For Display Only

Skilled Nursing Care