Direct Deposit Authorization Form

First Name *

Last Name *

Email Address *

Last 4 of SSN *

Employer Name *

I hereby authorize HRC Total Solutions, LLC, hereinafter called HRCTS, to initiate credit entries to my account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. I further authorize HRCTS, to initiate debits from the aforementioned account indicated below, and to debit the same from such account if an error is made in processing. Processing errors can include a payment that was made via my HRC Total Solutions VISA that was deemed ineligible, or if a forced post puts my flexible spending account with HRC Total Solutions in the negative.

Please Indicate Type of Bank Account *

Checking

Savings

Depository Name *

City *

State *

Routing Number *

Confirm Routing Number *

Account Number *

Confirm Account Number *

This authorization is to remain in full force and effect until HRC Total Solutions has received written notification from me of its termination in such time and in such manner as to afford HRC Total Solutions and DEPOSITORY a reasonable opportunity to act on it. This form will require a minimum of 2 days processing time to be updated in our system.

NOTE: ALL WRITTEN CREDIT/DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. HRC Total Solutions WILL NOT BE RESPONSIBLE FOR INCORRECT BANKING INFORMATION IF VOIDED DOCUMENTS ARE NOT INCLUDED WITH THIS FORM.

Terms & Conditions *

Agree