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Direct Deposit Agreement

  1. Type of Application*

  2. I hereby authorize the City of Cocoa to initiate credit entries and to initiate, if necessary, debit entries and adjustments for credit entries in error to my (our)

  3. Type of Account*

  4. Please type the cash amount of paycheck wanting to go to your checking account.

  5. Please type the cash amount of paycheck wanting to go to your saving account.

  6. as indicated above at the Financial Institution below, hereinafter called "Depository", to credit and/or debit the same to such account.

  7. Please type the name of your used financial institution in the space provided.

  8. Please type the name of the city in which the financial institution listed is located.

  9. Please type the name of the state in which the financial institution listed is located.

  10. Please type the zip/area code in which the financial institution listed is located.

  11. Please type the 9 digit transit number associated with the account under the financial institution listed.

  12. Please type the account number associated with the CHECKING account under the financial institution listed.

  13. Please type the 9 digit transit number associated with the account under the financial institution listed.

  14. Please type the account number associated with the SAVING account under the financial institution listed.

  15. Please send my pay stubs to my

  16. This authority is to remain in full force and effect until the City of Cocoa has received written notification from me of its termination in such a time and in such a manner as to afford the City of Cocoa and the Financial Institution named above a reasonable opportunity to act on it.

  17. By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.

  18. Leave This Blank:

  19. This field is not part of the form submission.