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NameAddressSignature DateComplete the form below and submit to your employer/payer. If your employer/payer prefers to use their own Candidate's Name , you may use this as a reference. City State ZIPEmail AddressDeposit Account TypesChecking AccountDeposit Amount:Indicate percentageor dollar amountAccount #:Routing #: 113024588Financial Institution: First Carolina BankSavings AccountDeposit Amount:Indicate percentageor dollar amountAccount #:Routing #: 113024588Financial Institution: First Carolina BankAuthorizationI authorize (employer/payer), and FirstCarolina Bank to automatically deposit my payroll check into my account(s) listed above. This includes my authorization to correct any entries made in error. This authority will remain in effect until this employer/payer has received written notication from me of its termination in such time as to afford employer and First Carolina Bank a reasonable opportunity to act on it. Please download form to e-sign 2023 BMTX, Inc., a wholly owned subsidiary ofBM Technologies, Inc. All Rights Reserved.BankMobile deposit accounts are provided by First Carolina Bank, Member FDIC & Equal Housing Lender.