Employee Direct Deposit Authorization and Agreement

Fax number: 781-341-2001

Employee: Retain a copy of this form for your records. Return the original to your employer.

Employer: Return this form to your payroll company. For clients using the online service, please retain a copy of this

document for your records.

Date: ____________________ Last 4 digits of Social Security Number: __ __ __ __

Company Name: _____________________________________________________________________________

Employee Name: _____________________________________________________________________________

Please include either (check one):

Voided check attach below Typed bank letter

I wish to deposit (check one): _______ % of Net Specific Dollar Amount $__________

Please fill out chart below for more than one account.

Bank Name

Last four of Acct #

Choose Account Type

Amount to deposit of net pay

checking or savings

$ or %

checking or savings

$ or %

I authorize my employer as noted above, CEOS Corporation dba @TimePay$, Harbor One bank and all financial institution(s)

involved in each transaction to deposit my pay automatically to the indicated account(s) and to make adjusting entries including

the removal of funds if the employer does not make them available, in which case, I waive any rights I may have to return debit

entries to my account and I personally guaranty the return of the funds in question. Deposits are normally available two (2)

banking days after payroll is processed. It is my responsibility to verify deposits on a per pay period basis before writing checks

against these funds. This Authorization can take up to three (3) pay periods to activate. I understand that neither my employer,

CEOS Corporation dba @TimePay$ or Harbor One bank is responsible for bank errors or bank fees. A return for a direct deposit

error is $7. Direct Deposit Financial services are provided in accordance with CEOS Corporation dba @TimePay$ Direct Deposit

Agreement, Harbor One bank / CEOS Corporation dba @TimePay$ Power of Attorney/Guaranty/Terms and Conditions and the

limitations and restrictions of the National Automated Clearing House Association. I may cancel these Direct Deposit(s) at any

time.

Employee Signature: _____________________________________________________________________ Date: ____________________

Account Holder Signature:_________________________________________________________________Date: ____________________