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CITY OF BELGRADE 91 E. CENTRAL BELGRADE, MT 59714 www.ci.belgrade.mt.us Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] 4/8/16 AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS I authorize the City of Belgrade, to initiate credit entries and to initiate, if necessary, debit entries and adjustments from any credit entries in error to my account(s) indicated below at the financial institutions(s) named below, to credit and/or debit the same account. Please note that advance checks cannot be direct deposited. If you signed up for an advance check you will continue to receive a check. Please check one of the following options: ❑ I would like 100% of my net check deposited to the following account. Financial Institution: City/State/Zip: Routing Number: Account Number: ❑ Checking ❑ Savings ❑ I would like my net check distributed as follows. Please note, if you choose to distribute by percentage, the total of the percent amounts need to equal exactly 100%. If you choose to distribute by dollar amounts, one of the accounts must say Remaining Balance. ❑ Percent OR ❑ Dollar Amt Financial Institution: City/State/Zip: Routing Number: Account Number: ❑ Checking ❑ Savings ❑ Percent OR ❑ Dollar Amt Financial Institution: City/State/Zip: Routing Number: Account Number: ❑ Checking ❑ Savings This authorization is to remain in full force and effect until the City of Belgrade has received written notification from me in such time and manner as to afford the City of Belgrade and the Financial Institution(s) a reasonable opportunity to act on it. * Please attach a photocopy of a blank check or a voided check. Employee’s Signature: Date: Please Print Employee’s Name: