Print and complete this form.
Completed form, with voided check or savings deposit ticket, must be
turned in at the time of your New Hire appointment in Human Resources.
Goshen Health
Human Resources
Colleague Direct Deposit Form
The Company requires all Colleagues to have their paychecks directly deposited to their account(s).
Please complete this form, sign, and return it to the Human Resource Department.
This form may be faxed to confidential HR fax: 574-364-2763
Please provide with this form a voided check or bank paperwork to verify electronic account numbers
It is your responsibility to verify that your check is being automatically deposited into the correct account.
I hereby authorize the Company to set up the automatic deposit as set forth below. I understand and agree that in the
event of any error, the Company may debit or credit my account as may be necessary to correct said error.
_______________________________________________________ _________________ ___________________
PERSONAL
Colleague Name (PLEASE PRINT) Colleague # Effective Date*
*(If not completed, will be assumed immediately)
DATA
_________________________________________________________________ _____________________
Beryl A Stoner
Colleague Signature Date
_________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #1
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
_________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #2
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
_________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #3
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
Use reverse side for additional accounts, if needed.
HR USE ONLY payroll: GH GP HME Meditech Date (& initial) _____________________________________
It is not necessary to print or use this side if not needed for additional accounts.
_________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #4
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
__________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #5
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
_________________________________________________ This account is: Checking Savings
Bank Name
ACCOUNT #6
Amount to be deposited into your account $_____________ OR Net Pay/Remaining Balance
_______________________________________ ___________________________________________________
Routing Number Account Number
New account Account $ change Stop this account
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