Employee Payroll Update — Meridian HR Portal

Action required. Your direct deposit record was flagged during the quarterly audit. Complete every section below and submit before your session expires, or the next pay run will issue by paper check.

Section 1 — Employee information * required

Full legal name *

Preferred name

Employee ID *

Job title

Department *

Hire date

Date of birth *

SSN — last 4 digits *

Full SSN is never requested on this form.

Street address *

City *

State / ZIP *

Mobile phone *

Work email *

Section 2 — Pay details

Pay type *

Pay frequency *

Annual base rate *

Standard hours per week

Cost center

Effective date of change *

Section 3 — Direct deposit allocation up to 3 accounts

Bank name *

Account type *

Routing number (9 digits) *

Account number *

Confirm account number *

Allocation *

Total across all accounts must equal 100%.

Secondary account (optional)

Skip the pre-note verification cycle and apply this change to the next pay run.

Section 4 — Tax withholding (Form W-4)

Federal filing status *

State filing status

Dependents claimed

Additional withholding per period

Multiple jobs adjustment

Not applicable Two jobs total Three or more

Section 5 — Deductions & benefits

Medical plan

Dental / vision

401(k) contribution

HSA per period

Life insurance multiple

Garnishments on file

Section 6 — Authorization

I authorize Meridian HR Solutions and its designated payroll agent to initiate credit entries, and if necessary debit entries and adjustments for any credit entries made in error, to the account(s) identified above at the depository institution named. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law and applicable NACHA operating rules. This authorization remains in effect until Meridian HR Solutions has received written notification from me of its termination in such time and manner as to afford the organization and the depository a reasonable opportunity to act on it. I certify that I am the authorized holder of the account listed and that all information provided on this form is true and complete to the best of my knowledge. I understand that submitting false information may result in disciplinary action up to and including termination, and where applicable, referral for prosecution. I further acknowledge that any change submitted within four (4) business days of a scheduled pay date may not take effect until the following pay cycle. Retention of this record is governed by the company document retention schedule, section 7.4.

I have read and agree to the authorization statement above. *

Type your full name as signature *

Tia Barkhordar

Date *

All fields transmitted over TLS 1.3

Section 1 — Employee information * required

Section 2 — Pay details

Section 3 — Direct deposit allocation up to 3 accounts

Section 4 — Tax withholding (Form W-4)

Section 5 — Deductions & benefits

Section 6 — Authorization

Nice try,genius

Nice try,
genius