Direct Deposit Authorization Form

Existing Direct Deposit Payer Information

Payer Name

Payer Address

City

State

Zip Code

Payer Phone Number

Your Information

Your Name

Your Social Security Number

Your Address

City

State

Zip Code

Your Home Phone Number

Your Cell Phone Number

Please deposit my:

(Ex. Payroll, Social Security, etc. as instructed below)

Crossbridge Community Bank, SSB

Routing Number: 291571348

Checking Account Number (10 digits):

Savings Account Number (10 digits):

Today's Date:

I hereby authorize the above named to deposit my payroll check or other distribution as indicated above. This request is to replace any previous authorization and will remain in effect until I change it in writing. I agree that any funds erroneously deposited into my account in excess of my authorized amount or then current salary may be withdrawn without liability or prior notice. If this form is not sufficient for Direct Deposit authorization, please forward the correct form to me for my signature.

Signature:

Today's Date:

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