Direct Deposit Authorization Form

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

I authorize Community Action Network to initiate credit (deposit) entries and, if errors occur, I authorize the correction of entries to my account as indicated.
I understand that I may discontinue this authorization at any time by giving written notice to Accounting.
I acknowledge this information will be used solely for the purpose of direct deposit.
I authorize the full deposit of my net income* acquired by Community Action Network.

*Net income: Remaining dollar amount after all taxes, voluntary deductions, and other bank account amounts have been deducted.

First Name

Last Name

Legal Name

Name that matches account owner's name

Account Type

If "Other," please indicate type below:

Bank or Institution

Bank Routing Number (ABA #)

Bank Account Number

Optionally, click here to attach a voided check or bank form with ABA Number. This will help us cross-reference the information input in this form to ensure there are no mistakes

Browse to choose a file

This step is optional. It ensures all entered information is correct.

Notes (Optional):

You will be asked to sign this form on the next page.

By signing this form, you agree to the aforementioned statements and attest to the accuracy of the provided information.

*****

Click here to learn more about Enabling JavaScript if user receives an error that looks something like "Please ensure JavaScript is enabled and try again"

Save my progress and resume later | Resume a previously saved form

Contact Information