This form is only available on a desktop computer with printing capabilities.

You will need to fill out the form, print it and submit the paper copy (or fax or scan) to our office, which is not able to be done on a mobile phone.

D&L ESI Direct Deposit Form

Full Name:       Date:

Last 4 digits of your social security #:        D&L Employee #: [REQUIRED]

My email address is: 

Check One:  NEW application     OR     I already have direct deposit, this is a CHANGE of bank info

(1)  TYPE in the information above (2)  PRINT This Page (3)  READ the authorization below and SIGN your name (4)  ATTACH a blank check from the account in which you want us to deposit your money into. (5)  SEND the completed form to D&L via mail, fax, hand delivery or scan/email (keep a copy for your records) (6)  Your pay stubs will come FROM Please ADD this email address to your email "safe list" to assure that you receive your pay stubs.

Important!  Please read and sign the following:

The undersigned hereby authorizes his or her employer or its designee (“Employer”) to deposit any sums Employer owes to me into the bank or other financial institution (“Financial Institution”) accounts identified below.  The undersigned also authorizes Financial Institution to receive and accept any such deposits and credit the same to my account.
If any deposit is made to my account in error by Employer, Financial Institution is authorized to return the erroneous payment to Employer and to debit my account for the same in an amount not to exceed the amount of the erroneous deposit.
This authorization shall remain in effect until revoked by the undersigned in writing so as to allow Employer and Financial Institution a reasonable opportunity to act.

Employee Signature: _____________________________________  Date: ______________


Write "VOID" in the "pay to" field of the check (do not attach a deposit slip)


Routing #: 

Account #: