A2-104-directdepositauthorization-1106qxp Forms - lhi benefitsportal 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Name and the last four digits of your Social Security Number (SSN) at the top of the form.
3. Fill in the Date and your Employer's name in the designated fields.
4. If you choose to waive Direct Deposit Authorization, check the appropriate box. Otherwise, proceed to fill out your direct deposit information.
5. You can set up a maximum of three accounts. For each account, enter the Account Type (checking or savings), Transit/ABA Number, and Account Number. Specify if it's a Full Net Deposit or a Partial Deposit by checking the corresponding box.
6. If you select Partial Deposit, indicate the amount you wish to deposit for that account.
7. At the bottom of the form, read and understand the Authorization Statement before signing and dating it.

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