DIRECT DEPOSIT AUTHORZATION FORM

Employee Name:____________________________________________________

Social Security #:__________________ Department:_____________________

I hereby authorize and request the City of Nashua to make payment of my net earnings by initiating credit to my account in the financial institution below, hereinafter referred to as “bank”. I also authorize and request the bank below to accept such credit to my account without the bank being responsible for the correctness thereof.

If such payment at any time causes funds to which I am not entitled to be deposited to my account, I authorize the City to direct the bank to return said funds, and hereby authorize the bank to accept and process such debit to my account with the bank being responsible for the correctness thereof.

I understand that the City may terminate this agreement at any time, and will send me written notice thereof. I understand that I may terminate this agreement at any time upon written notification to the NASHUA SCHOOL DISTRICT C/O HUMAN RESOURCES DEPARTMENT. This notification will be effective only for entries by the City after receipt of such notice and a reasonable time to act on it.

I understand that this direct deposit agreement may take up to three pay periods before becoming effective.

BANK INFORMATION:

Please fill out this section in its entirety. This agreement will override any previous direct deposit agreement with the City. The City can make up to two direct deposit transactions per employee for each pay period. If credits are to be made to a checking account, a voided check (or copy) must be attached to this form.

First Transaction:

Name of Bank:________________________________________________________

Account #:____________________________________________________________

Routing #:____________________________________________________________

ÿ Fixed Amount: $ ÿ Checking Account

ÿ Percent: % ÿ Savings Account

Second Transaction:

Name of Bank:________________________________________________________

Account #:____________________________________________________________

Routing #:____________________________________________________________

ÿ Fixed Amount: $ ÿ Checking Account

ÿ Percent: % ÿ Savings Account

____________________________________________ _____________________

Employee Signature Date

REV: 12/9/05