Sodexo

PO Box 17033
Augusta, GA 30903
Payroll Fax: 925-598-9558 / Email: cossragent@[Link]
Direct Deposit Authorization Form (Add, Change, Delete)

Instructions: This form is completed to add a new, change or delete a Direct Deposit account. To ensure prompt processing, provide all required information. All fields with the ( ◄) symbol indicate
information is required for processing. To modify more than three direct deposit accounts, use multiple forms as needed.
Note: Employees may have their net pay allocated and deposited into more than one bank account. New accounts must go through a “pre-notification process” (your bank account
information must be validated with the bank before direct deposit can begin), which will take up to two pay cycles. If you are currently receiving a Live Check, you will continue to do so
until your request has been successfully processed. Keep this form until you have verified that your request has been processed.
Section 1: Employee Information

First Name◄ Middle Initial Last Name◄ Suffix

Employee ID◄ OR: Employee File Number ◄ AND Comp. Code (Pay Group) ◄ Date of Birth◄

Phone Number◄ Zip Code ◄

Note: Your “Employee ID” is displayed on your Pay Statement (in the Miscellaneous” section) or you may use your “Company Code (Pay Group)” and “Employee File Number” (from the
top left corner of your Pay Statement). Also provide your “Date of Birth”, “Phone Number”, and “Zip Code” for validation purposes.

By signing below, I authorize the above-named company and/or its representative to initiate direct deposit (credit) entries. If funds to which I am not entitled are deposited to my account, I authorize ADP COS and/or its representatives to direct the bank to return said
funds (debit). I understand that my bank must be a member of the “Automated Clearing House (ACH)” in order for my net pay to be processed via Electronic Funds Transfer (EFT). I understand I will be notified if there is a problem with my ACH account transaction
during pre-note as stated above. This authorization is to remain in effect until it is changed or canceled by me via the Direct Deposit Authorization Form or my employment terminates (Client reserves the right to cancel Direct Deposit on termination). I understand that I
must allow sufficient time as noted above for the processing of such changes or cancellation.

Employee Signature:
Signature◄ Date of Request◄

Contact Email Address◄ Contact Telephone Number◄

For a bank account, use reference below to locate your Bank Account Number and Bank Transit Routing Number. If you only have one (1) account in the direct deposit program, the entire amount
of the Net Pay will be deposited into that account if you select Full Deposit .If you select Partial Deposit , the balance will be issued in a live check. If you specify two (2) or more accounts, the
designated dollar amount ($) of your Net Pay will be deposited into the specified accounts. Any remaining Net Pay will then be deposited into the account designated as Full Deposit or issued in a live
check.

Account One (1) Details -- Check One◄: New Change Cancel

Savings Partial
Account Select Deposit
Deposit
Select Account Type Amount of Net Pay
Type◄: Checking Full (indicate amount to be deposited if its partial deposit)◄:
Account Deposit
Account Two (2) Details -- Check One: New Change Cancel
Enter Bank Transit Routing Number (series of nine (9) numbers,
NOT starting with a "5"):
Enter Bank Account Number:

Savings Partial
Account Select Deposit
Deposit
Select Account Type Amount of Net Pay
Type◄: Checking Full (indicate amount to be deposited if its partial deposit)◄:
Account Deposit
Account Three (3) Details -- Check One: New Change Cancel
Enter Bank Transit Routing Number (series of nine (9) numbers,
NOT starting with a "5"):
Enter Bank Account Number:

Savings Partial
Account Select Deposit
Deposit
Type
Select Account Amount of Net Pay
Type◄: Checking Full (indicate amount to be deposited if its partial deposit)◄:
Account Deposit

Please use the below space to provide a scanned image of check copy, bank slip, etc that would enable in verifying the account information:

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Copyright (c) 2011 ADP Comprehensive Outsourcing Services. All rights reserved. 12/2013