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New Bank Account Request Form
Use the new account for the following services:Checkmark the applicable services
Check Signature:
Click here for the Signature Form
Does the new account need to be mapped to your General Ledger Export?

  • If the account has an ACH debit block you will need to contact your bank to ensure that Empeon is approved for debiting this account. Failure to do so may result in funding delays and bank fees. 
  • The form must be received at least four business days prior to the effective Check Date.
  • Please attach a copy of a voided check, Empeon will not accept this form without a copy of a voided check.
I agree to the $25 bank account setup fee

Form Content
·    I understand that it is the client’s responsibility to verify that all items were set up as requested, and it is the client’s responsibility to test the accuracy of the calculations resulting directly or indirectly from this request
·    In no event will Empeon be liable for any direct, indirect, incidental, consequential, punitive, or monetary damages, occurring as a result of this request, whether or not such damages were foreseeable and even if Empeon was advised that such damages were likely or possible