The sample Direct Deposit Revocation of Prior Authorization forms are available free below to download, customize and print for your business or organization’s Human Resources Dept.
Does your small business have Direct Deposit as a choice for payroll for your employees and for various reasons had a need to cancel it?
If yes, then you might need one of the forms below such as the Revocation of Prior Authorization for an Automatic Direct Deposit and/or the Revocation of Prior Authorization and Authorization for Preauthorized Payments.
The Revocation of Prior Authorization and Authorization for Preauthorized Payments form below is what you provide to the company, a copy to the institution that had your old accounts, and a copy to the Financial Institution and includes:
- Company Name and Address
- Statement – I/we revoke all prior authorizations of the company (defined above) to initiate preauthorized payments to debit entries to any of my/our accounts at any financial institution. I/we authorize the Company to initiate debit entries to my/our account (identified below) at the Financial Institution (identified below) for the purpose of accomplishing the following preauthorized payments: __Amount $, __May Vary, __May not Exceed $.
- Regarding any right I/we have to receive notice at least 10 days prior to the due date of any payment of a varying amount, I/we choose to receive this notice ___ ONLY when the amount of my/our payment falls outside the range of $_________ to $_________ OR ___ ONLY when the amount of my/our payment differs from the most recent payment by more than $_________.
- See the form below for the rest of the statements…
The Revocation of Prior Authorization for an Automatic (Direct) Deposit form below is what you provide to any third party initiating any automatic direct deposits to your old account and includes:
- Company Name and Address
- Statement – I/we revoke all prior authorizations of the company (defined above) to initiate credit entries to any of my/our accounts at any financial institution. I/we authorize the Company to initiate credit entries, and to initiate any debit entries needed to correct erroneous credit entries, to my/our account (identified below) at the Financial Institution (identified below) for the purpose of automatically depositing funds in the account. I/we acknowledge that the origination of these transactions must comply with the U.S. law.
- Account – Checking/Share Draft, Savings/Share Savings, Other
- Account Number
- Taxpayer ID Number(s)
- Signature(s) – Print Name and Date
- Note – *Provide this form to any third party initiating any automatic direct deposits to your old account.
Click on the link(s) to download the Direct Deposit Template(s) below:
Revocation of Prior Authorization / Direct Deposit Revocation
Revocation of Prior Automatic Direct Deposit
