Sample Direct Deposit Authorization Form

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Direct Deposit Authorization
Authorization for Electronic Funds Transfer
This form authorizes the depositor to initiate electronic fund transfers to the account holder's designated bank account.
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A
Account Holder Information
1Full Name
Jane A. Doe
2Email Address (optional)
3Street Address
456 Elm Street
4City
Brooklyn
5State
NY
6ZIP Code
11201
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B
Bank Account Information
7Name of Financial Institution
First National Bank
8Account Type
✓Checking    Savings
9Bank Address
100 Main Street, New York, NY 10001
10Routing Number (9 digits)
021000021
11Account Number
123456789012
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C
Depositor & Authorization
12Depositor Name (employer, agency, or organization)
Acme Corporation
The account holder authorizes the above-named depositor to initiate direct deposit (credit) entries, and corrective adjustments for any credit entries made in error, to the account indicated above. This authorization remains in effect until the depositor receives notice of revocation in sufficient time to act.
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D
Certification & Signature
By signing below, the account holder certifies that the information provided above is accurate and complete and authorizes the electronic funds transfers described in Section C.
13Signature
Jane A. Doe
14Printed Name
Jane A. Doe
15Date
01/01/2026
Direct Deposit AuthorizationContains Personally Identifiable InformationPage 1 of 1

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Create Your Form

What is a direct deposit authorization form?

A direct deposit authorization form is a written statement that authorizes an organization — your employer, a government agency, a pension fund, or any other paying entity — to deposit funds electronically into your bank account. Instead of receiving a paper check, payments arrive automatically.

The form includes your personal details, your bank's routing number, your account number, and your signed authorization — putting your intent to receive electronic payments in writing.

Some organizations also ask for a voided check alongside this form to verify your routing and account numbers. You can generate one on our voided check page.

When do you need one?

  • Starting a new job and setting up payroll

  • Switching banks or opening a new account

  • Government benefits (Social Security, VA, tax refunds)

  • Pension or retirement benefit deposits

  • Freelance, contractor, or commission payments

  • Insurance claim or settlement payouts

  • Scholarship or financial aid disbursement

  • Changing from paper checks to electronic deposit

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