DL-E1

DIRECT DEPOSIT REQUEST FORM

          The School Board provides a benefit for contracted employees paid monthly to have payroll amounts automatically deposited to the employee’s checking or savings account through direct payroll deposit. The direct deposit must go to a financial institution (bank or credit union) in the Federal Reserve System. The employee is required to complete the authorization form below that provides the account and routing information for the deposit.

          Please complete the form below and send to Payroll Department no later than the fifteenth (15^th) of the month.

CULPEPER COUNTY SCHOOL BOARD

Company Name

_____________________________________________________________________________

Bank Name (Depository) and Office

_____________________________________________________________________________

City                                                 State                                           Zip Code

______________________________       ______________________________

Date                                                  Printed Employee Name

                                                        ______________________________

                                                       Signature of Employee

                                                        ______________________________

                                                       Bank Deposit Account Number

To ensure accuracy of this service, please attached a VOIDED CHECK to this form. This form will remain valid until written termination has been received from the employee.