DIRECT DEPOSIT

Name

Social Security Number

I (we) hereby authorize Bernards Township Board of Education, hereinafter called “BTBOE,” to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit in error to my (our) Checking/Savings account(s) indicated below and the depository institution(s) named below, hereinafter called “DEPOSITORY,” to credit and/or debit the same to such account(s).

You may apply your Direct Deposit to more than one account.  Please indicate the amount or percentage you would like deposited into each account.

Depository Name

Branch

City, State

Zip

Transit/ABA Number (9 Digits)

Account Number

Checking/Savings (choose one)

Amount to be deposited ($ or %)

Depository Name

Branch

City, State

Zip

Transit/ABA Number (9 Digits)

Account Number

Checking/Savings (choose one)

Amount to be deposited ($ or %)

This authority is to remain in full force and effect until BTBOE has received written notification from me (or either of us) of its termination in such time and in such manner as to afford BTBOE and DEPOSITORY a reasonable opportunity to act on it.

Date                                                                               Signature