Direct Deposit Authorization

Wilmington Mental Health
3825 Market St., Ste 4
Wilmington, NC 28411

P 910.777.5575
F 910.777.5273
info@wmhwc.com

Direct Deposit Authorization
Instructions: (1) Fill out and sign this form, (2) attach a voided check for each checking account (not a deposit slip), and (3) return form to your payroll manager. This document must be signed by contractors requesting automatic deposit of paychecks.
Choose one:

EmployeeContractor / 1099Other
New AccountAdditional AccountReplacement Account
ACCOUNT 1.
Bank Name:
Account 1 type:

CheckingSavingsHSA
Routing Number (ABA number):
Account Number:
Percentage % or dollar amount $ . to be deposited to this account.
ACCOUNT 2.
Bank Name:
Account 1 type:

CheckingSavingsHSA
Routing Number (ABA number):
Account Number:
Attach a voided check for each account here

Cancelof
AUTHORIZATION

This authorizes Wilmington Mental Health, PLLC (“the Company”) to send credit entries electronically or by any other commercially accepted method, to my account indicated above and to other accounts I identify in the future. This authorizes the financial institution holding the Account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable U.S. Law. This authorization will remain in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it.
Name on Bank Account:
SSN/FEIN:
Account Holder Name:
Account Holder Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: