Please complete either the Direct Deposit Authorization or Alternative Payroll Request Form so that you can be paid on time through the financial institution of your choice.

Direct Deposit Authorization Form

Please complete this direct deposit authorization form. It will automatically be submitted to our HR team for processing through our payroll system.

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Name *

First

Last

Company Name (If applicable)

Only complete this if you are the owner of the company

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Employer Identification Number/Social Security Number *

Work Status *

• Employee
• Independent Contractor
• Business
• I Don’t Know

Reason for completing this form *

• New Direct Deposit Setup
• Changes to Current Direct Deposit

Financial Institution Name *

List the name of your bank, credit union, etc.

Branch Name

If applicable

Routing/Transit Number *

Bank routing numbers are usually 9-digits

Account Number *

Bank account numbers are usually 1-17 digits

Branch Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Type of Account *

• Checking
• Savings

Confirm that you want 100% of your check deposited into this account *

• Yes

Authorization

I hereby authorize Rodgers Security Solutions, Inc. to deposit my pay automatically to the account(s) indicated below and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford Rodgers Security Solutions, Inc. a reasonable opportunity to act on it. I also accept that a copy of this form is as valid as the original. *

• Yes

Today's Date

Type the 2-digit month, 2-digit day, and 4-digit year

Submit

This form is designed for workers who cannot accept compensation through direct deposit.

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Name *

First

Last

Email *

Phone Number *

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Preferred Payment Method *

• Zelle
• Check
• Other

Preferred Payment Method Information *

Please provide information for your alternative payment method.

Certify that the information you provided is accurate and truthful, and that you give permission to Rodgers Security Solutions to issue your payment using the method that you have indicated above. *

• Yes

Submit