Massachusetts Direct Deposit Form 3
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MA/RI
Employer Authorization
Direct Deposit Form
Company Name
Company Address
City, ST, Zip

Employee Name
Employee Address
City, ST, Zip
Employee/Payroll #
Telephone Number

-

-

I hereby authorize direct deposit to my account at Webster Bank, 145 Bank Street, Waterbury,
CT 06702.
Webster Bank Routing/Transit #

211370231

Webster Bank Account #
Webster Bank Account Type

Checking

Savings

Date:
Signature:

Please return this form and a voided check from your Webster Bank account, to your Payroll Department.