Payroll Deduction Direct Deposit Form

(Enter your information on this form and print two copies. However, we suggest that you only enter accout
number on your printed copies.   Submit one copy to your employer's payroll or human resources
department and keep the other copy for your records.)

Your Information Your Employer's Information

Name

Name

Address

Address

City

City

State Zip Code

State Zip Code

Phone Number Contact
Phone

Forest Bluff Financial Services Information

Forest Bluff Financial Services

123 Central Avenue

Lake Bluff, IL 60044

Contact Phone Number

Institution Routing Number - 123456789
(This number can be found at the bottom of a check from the receiving insitution. It is nine digits long and is bracketed by computer symbols that look like vertical lines followed by two dots. You can also get the number from your institution. If you are still unsure, attach a voided check to this form.)

Account you wish funds deposited into
Account Type Checking Savings Other (describe)
Account Number (enter only after printing) # # #
Amount to be deposited $ $ $
Any special instructions

I authorize (your employer) to automatically deposit my net
pay into the account(s) listed above at Forest Bluff Financial Services. This authorization will remain in effect until
I give written notice to change it.

_________________________________________________ ____________________
Signature      Date

Print two copies, enter your account number, give one to your employer and keep one for your records.