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FINANCIAL INSTITUTION NAME (PLEASE PRINT) BRANCH New request Cancel existing Payroll Vendor CITY STATE SIGNATURE DATE (NINE DIGITS BETWEEN THE l: l: SYMBOLS) (DIGITS AFTER THE l: l: SYMBOLS) PLEASE EMAIL MY BSB REMIT STATEMENT TO THE FOLLOWING EMAIL ADDRESS: PLEASE PRINT LEGIBLY checking account. savings account. This authority remains in effect until I cancel it in writing. Staple voided check in this area TRANSIT ROUTING NUMBER: ACCOUNT NUMBER INFORMATION: DIRECT DEPOSIT We are pleased to offer you a new convenience - Direct Deposit. You can have your check automatically deposited in your checking or savings account . You don't have to change your present banking relationship to take advantage of this service. Here's how it works: You will receive a "Remit Statement" via email showing the itemized invoices and the amounts paid. We believe you will like the added convenience of having your net payments automatically desposited for you. Direct Deposit is safe, convenient, and easy. To take advantage of this service, please complete the following authorization form and return it to the Accounts Payable Department. The address listed below in red. The authorization form provided below, gives Butte-Silver Bow and your financial institution authority to deposit your money to your account. Please complete the form in order to take advantage of Direct Deposit. Instructions: 1. Mark the box before the type of account to indicate whether your money will be desposited in a checking or savings account. 2. Fill in your name, financial institution name and location, check the type of action (new or cancel), and date. 3. Attach a voided check for verification of all financial institution information. If you are unable to attach the voided check, please fill in your account number. 4. PLEASE SIGN THE FORM AND INCLUDE AN EMAIL ADDRESS! Remit Statements will NOT be mailed via any other method. EMPLOYEE'S OR VENDOR'S AUTHORIZATION - Please fill out & return to: Instructions are above in the right hand column. I authorize you and the financial institution listed below to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries made in error to my: Accounts Payable; 155 W. Granite St. Rm. 207, Butte MT 59701 If you have questions about the Direct Deposit Program, please call Accounts Payable at [PHONE REDACTED]. If you have questions about receipt of a payment, please call the Clerk & Recorder at (406) 497-6335. X ---PAGE BREAK---