DIRECT DEPOSIT

EMPLOYER NAME

EMPLOYEE NAME

EFFECTIVE DATE

ADDRESS

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

Select or enter value

ZIP

Social Security Number (Enter Last Four Digits Only)

OPT-IN CONSENT

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PHONE

Phone

PAYROLL DEDUCTIONS/DIRECT DEPOSITS

I request my payroll deduction/direct deposit be placed in the following accounts:

BANK/CREDIT UNION

BANK ABA (ROUTING NUMBER)

ACCOUNT NUMBER

TYPE OF ACCOUNT

Checking

Saving

CHOOSE YOUR DEDUCTION METHOD

Deduction Amount

% Net Pay

DEDUCTION AMOUNT

% NET PAY

RAPID! PAYCARD ISSUANCE AUTHORIZATION FORM

(Direct deposit number to be assigned and entered by Magnet HR Group)

AUTHORIZE

I authorize MAGNET HR GROUP, LLC to withhold the indicated amount(s), if available, from my pay, and deposit directly into the account(s) shown and/or I hereby authorize MAGNET HR GROUP, LLC to assign a rapid! PayCard and initiate credit entries and any correcting entries to my assigned rapid! PayCard account. The direct deposit(s) will be made on each payday, unless I notify MAGNET HR GROUP, LLC in writing of my intent to cancel. Upon MAGNET HR GROUP, LLC’s receipt of a request to cancel a direct deposit authorization, it shall become effective after a reasonable opportunity to act upon it. In the event funds are deposited erroneously into my account, I authorize MAGNET HR GROUP, LLC to debit my account(s) not to exceed the original amount of the credit. I understand that MAGNET HR GROUP, LLC reserves the right to refuse any direct deposit request. I also understand that all direct deposits are made through the Automated Clearing House (ACH), and that funds availability is subject to the terms and limitations of the ACH as well as my financial institution. Note: If sending this form electronically, please type your initials and the last 4 digits of your social security number in the signature field. If sending or faxing a paper copy, please print out and sign your name(s) in the signature box.

I authorize MAGNET HR GROUP LLC

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