Contractor Payment Distribution - Rodgers Security Solutions Inc.

Payment Distribution Authorization Form [Contractor]

This form is for independent contractors to provide us with preferred payment distribution information for services rendered.

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Name

First

Last

Company Name (If applicable)

Only complete this if you are the owner of the company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer Identification Number/Social Security Number

Reason for completing this form

New Direct Deposit Setup
Changes to Current Direct Deposit
New Alternate Payment Setup

ALTERNATE PAYMENT INFORMATION: Zelle

Please provide your Zelle information below

DIRECT DEPOSIT INFORMATION

Only complete this section if you are providing direct deposit information and not an alternative payment method.

Financial Institution Name

List the name of your bank, credit union, etc.

Branch Name

If applicable

Routing/Transit Number

Bank routing numbers are usually 9-digits

Account Number

Bank account numbers are usually 1-17 digits

Branch Address

Address Line 1

Address Line 2

City

State

Zip Code

Type of Account

Checking
Savings

CONFIRMATIONS

I confirm that I want 100% of my pay deposited into this account

Authorization

I hereby authorize Rodgers Security Solutions, Inc. to deposit my pay automatically to the account(s) indicated above and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford Rodgers Security Solutions, Inc. a reasonable opportunity to act on it. I also accept that a copy of this form is as valid as the original.

Today's Date

Type the 2-digit month, 2-digit day, and 4-digit year