AUTHORIZATION FOR PAYROLL/EXPENSE REIMBURSEMENT DIRECT DEPOSIT

Utah Legal Services

Please print or type all information.

Enter the required data in the boxes below regardless of whether you are submitting an Enrollment or Change
(Section A) or a Cancellation (Section B)

Employee Number Name Social Security Number

SECTION A - ENROLLMENT OR CHANGE Complete this section for new enrollments or changes in
financial institutions, accounts, or amounts. We suggest you attach a voided check (for checking) or deposit
slip (for savings) or photocopy thereof to reduce the chance of error in transcribing account data.

Check one:  This is a new enrollment.  This is a change

ACCOUNT
Bank Name Account type  Checking  Savings

Routing No Deposit amt  Net Pay  Fixed Amt $__________

Account No

ACCOUNT 2 If you fill in this second account, the remaining balance of your net pay (after deductions and
direct deposit to Account 1) will go to Account 2.
Bank Name Account type  Checking  Savings

Routing No Deposit amt  Balance/Remainder of Net Pay

Account No

I hereby authorize Utah Legal Services, inc., (ULS) to direct the net amount and/or fixed dollar amount of my
employee pay directly to the account(s) indicated above and to correct any errors which may occur from these
transactions. I also authorize the financial institution(s) to post these transactions to these accounts. This
authorization is to remain in force until ULS receives written notice from me to cancel or change this
authorization. I also acknowledge that ULS may initiate termination of my direct deposit if I do not comply with
time reporting requirements.

EMPLOYEE SIGNATURE DATE

SECTION B: CANCELLATION Complete this section and the header boxes above Section A to cancel
the Direct Deposit Authorization. This section will not go into effect until one working day after it is
received in the State Support Unit.

I hereby cancel the authorization for Utah Legal Services, Inc., to originate direct deposit entries to my
checking/savings account(s).

EMPLOYEE SIGNATURE DATE