FDIC Insurance up to the maximum allowed by law. Citizens Access and Citizens Bank, N.A. are treated as the same entity for the purposes of

calculating FDIC insurance limits and deposits.

© Copyright 2021 Citizens Financial Group, Inc. All rights reserved. Citizens AccessTM is a division of Citizens Bank, N.A.

Direct Deposit Authorization Form

Sign a completed Direct Deposit Authorization Form and provide to your payroll department to request Direct Deposit from your paycheck into your Citizens Access account.

Employee Information:

_________________________________________________________________________________________________ Employee Full Name

_____________________________________________ ________________, _________ ___________________ Home Address (if applicable) City State Zip Code

_____________________________________________ __________________________________________________ Employee Social Security Number (if applicable) Employee ID (if applicable)

___________________________________________________________________________________________________________

Employer Name (if applicable):

_________________________________________________________________________________________________ Employer Name

_____________________________________________ ________________, _________ ___________________ Employer Address City State Zip Code

___________________________________________________________________________________________________________

Direct Deposit Instructions:

Please have my paycheck automatically deposited into the following account:

Citizens Access_________________________________ 011601443 ________________________________________ Bank Name Routing Number

_____________________________________________ __________________________________________________ Citizens Access Savings Account Number Deposit Amount (Percentage or Dollar Amount)

To find your account number, please take the following steps: 1. Sign-in to your Citizens Access account2. Select the relevant account3. Click “View all account details”4. Next to Account Number, select “Show” to unmask all the digits of your account number

___________________________________________________________________________________________________________

I hereby authorize my employer, ___________________________, and Citizens Access to automatically deposit my paycheck into my Citizens Access account listed above, disbursing only the specified dollar amount or percentage each pay period. This authorization will remain in effect until I give written notice to cancel it.

___________________________________________________________ ___________________________________ Signature Date