CENTERVILLE COMMUNITY SCHOOL DISTRICT 
 
EFFECTIVE 7/1/19 
INSURANCE 
HEALTH SAVINGS ACCOUNT 
PAYROLL DIRECT DEPOSIT AUTHORIZATION (PRE-TAX DOLLARS) 

 
EMPLOYEE  NAME ______________________________________________ 
 
TODAY’S DATE________________ 
 
BANK NAME AND ADDRESS: 

 

 	  

BANK ACCOUNT NUMBER:  	 
 
CIRCLE ONE:  CHECKING OR SAVING 

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $______________ 

 
PLEASE ATTACH A VOIDED CHECK FOR VERIFICATION OF BANK NUMBER