Use this form to initiate a Direct Deposit into your The Bancorp Bank

Direct Deposit/Payroll Deduction Authorization for my The Bancorp HSA Account

1. Complete Part A of this authorization form.
2. Complete Part B with your banking information.
3. Sign at Part C.
4. Return the completed form to your employer.

Part A

I authorize ________________________________(employer name) to initiate credit entries, and, if necessary, to initiate any debit entries to correct a previous credit error, to my account at The Bancorp Bank. I authorize the following credit to be made (check only one box):

    Employer Contribution.
    Credit my entire net paycheck.
    Credit $______________ of my gross pay.
    Credit ______________% of my gross pay.
    Credit $______________ of my gross pay into account one and $___________ into account two.
    Credit ______________% of my gross pay into account one and  ___________% into account two.

Part B

Bank Name: The Bancorp Bank

Bank Routing Number: 031101114

Health Savings Account Number: __________________________________________________

Account Holder Name (please print):_________________________________________________

(Secondary Account Information)

Bank Name: __________________________________________________________________

Bank Routing Number: __________________________________________________________

Health Savings Account Number: __________________________________________________

Part C

I understand that this authorization replaces any previous authorization and will remain in effect until my employer receives written notification from me of its termination.

Name: _______________________________________

Signer: _______________________________________

Date: ____________________

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