FACT Relief Direct Deposit Form

Please complete the form below. All required fields must be completed in order to be submitted. Thank you!
If you have any questions, please contact Jennifer Parker at jparker@factrelief.org.

Contact Information

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Layout

Phone *

Email *

Bank Account Information

Layout

Bank Location (City, State) *

Routing Number *

Account Type *

Account Number *

Authorization and Consent

I hereby authorize Families and Communities Together (FACT) Relief to direct deposit my paycheck or reimbursement to my account. FACT Relief is not responsible for any money that is not credited in a timely manner due to holidays and bank processing schedules. If your money is not in your account on payday, first check with your bank, then contact your payroll clerk.

Signature *

Date of Signature *

Please complete the form below. All required fields must be completed in order to be submitted. Thank you!If you have any questions, please contact Jennifer Parker at jparker@factrelief.org.

Contact Information

Bank Account Information

Please complete the form below. All required fields must be completed in order to be submitted. Thank you!
If you have any questions, please contact Jennifer Parker at jparker@factrelief.org.