Employers: Payroll Direct Deposit Setup Form

Company Name

Payroll Frequency

Organization EIN

Mailing Address

City/Town

State/Province

ZIP/Postal Code

CONTACTS
(If a contact is the same person for more than one role, please enter information in all sections)

Payroll Representative Name

Payroll Representative Email

Payroll Representative Phone

Human Resources Representative Name

Human Resources Representative Email

Human Resources Representative Phone

Benefits Representative Name

Benefits Representative Email

Benefits Representative Phone

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