directdeposit – Fellow Travelers

Name *

First

Last

Social Security Number *

Address *

Address Line 1

City

State

Zip Code

Date of Birith *

Phone Number *

Email *

Date of Hire (Your FIRST day working / being paid) *

Company Name *

Local Tax Jurisdiction:

Where you want your local wage taxes sent (Note: Many places do not have local tax. It is ultimately your responsibility to pay local taxes).

Wage Type *

Salary
Hourly

Annual Salary (Yearly Pay) *

Hourly Pay Rate *

Required Payroll Deductions

Enter deductions you want from your payroll, such as child support

Routing Number *

Bank Account Number *

Account Type *

Checking
Savings

Deposit Split *

$ to Deposit into First Bank Acct. *

% to Deposit into First Bank Acct. *

2nd Bank Name *

2nd Routing Number *

2nd Account Number *

2nd Account Type *

Checking
Savings

2nd Deposit Split *

$ to Deposit into 2nd Bank Acct. *

% to Deposit into 2nd Bank Acct. *

3rd Bank Name *

3rd Routing Number *

3rd Account Number *

3rd Account Type *

Checking
Savings

3rd Deposit Split *

$ to Deposit into 3rd Bank Acct. *

% to Deposit into 3rd Bank Acct. *

4th Bank Name *

4th Routing Number *

4th Account Number *

4th Account Type *

Checking
Savings

Replacing Existing Bank Info? *

Yes
No

Prior Bank Name on File *

For Security Purposes

Prior Bank Routing Number *

For Security Purposes

Prior Bank Account Number *

For Security Purposes

Notes

Disclosure