Direct Deposit Authorization

I formally declare my choice to participate in receiving reimbursement via automatic deposit. I understand that I must submit a voided check which clearly shows my account routing information. This voided check is attached to this form. I understand that the agency will hold my financial information confidential. This information will be stored within a secure location in the office which cannot be accessed by individuals outside of agency administrative personnel or its owners. I understand it is my responsibility to notify Transformations, in writing, two weeks (fourteen days) prior to any changes to my bank routing information or of my decision to stop participating in automatic deposit for reimbursement. I understand that the agency will notify me of any issues preventing receipt of reimbursement immediately and will work to rectify the situation as quickly as possible. I understand that in the event my banking information changes, or needs to change immediately, the agency will work as quickly as possible to address. I further understand that I may be reimbursed via paper check during this transition. I understand that I will receive a paper form indicating what charges/clients were represented on my automatic deposit, and that this will be placed in my mailbox on Thursdays. I understand that I will be reimbursed according to customary and accepted practices of the agency. My signature below indicates that I understand this declara