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I hereby authorize City of Iowa City hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments
for any credit entries in error, to my account(s) indicated below and the financial institution named below, hereinafter called DEPOSITORY, to credit
and/or debit the same to such account. Your first pay check/stub will be a payroll check due to the pre note procedure that verifies bank account
information. The second pay check/stub will be direct deposited barring no errors on the pre note.
SECONDARY1 DEPOSITORY #9996 SELECT ONE: Checking Account Savings Account
FINANCIAL INSTITUTION:
C I T Y : S T A T E : Z I P :
ROUTING NO: ACCOUNT NO:
AMOUNT___________________
SECONDARY2 DEPOSITORY #9997 SELECT ONE: Checking Account Savings Account
FINANCIAL INSTITUTION:
C I T Y : S T A T E : Z I P :
ROUTING NO: ACCOUNT NO:
AMOUNT_____________________
SECONDARY3 DEPOSITORY #9998 SELECT ONE: Checking Account Savings Account
FINANCIAL INSTITUTION:
C I T Y : S T A T E : Z I P :
ROUTING NO: ACCOUNT NO:
AMOUNT_____________________
PRIMARY DEPOSITORY #9999 SELECT ONE: Checking Account Savings Account
FINANCIAL INSTITUTION:
C I T Y : S T A T E : Z I P :
ROUTING NO: ACCOUNT NO:
AMOUNT_____100% NET________________
This authority is to remain in full force and effect until COMPANY and DEPOSITORY has received written notification from me of its
termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
NAME: EMPLOYEE NO:
DATE: SIGNED:
I elect to have my pay stub sent electronically to me through email in lieu of receiving a
paper copy.
Email Address__________________________________________________________
************MANDATORY************
ATTACH A VOIDED CHECK, SAVINGS DEPOSIT STUB, BANK CARD. OR A
LETTER FROM EACH BANK WITH ACCOUNT INFORMATION TO THE
BOTTOM OF THIS FORM FOR VERIFICATION
AUTHORIZATION AGREEMENT
FOR AUTOMATIC DEPOSITS