Payroll Deduction/Direct Deposit Authorization

Payroll Deduction/Direct Deposit Authorization

Employer Payroll Deduction Authorization
Member Name^*:
Account #^*:
Employer^*:
SSN/TIN^*:
Home Phone^*:
Work Phone:
Payroll #^*:
Authorization^*:		Initial Authorization Change In Authorization

By submitting this form, I hereby authorize my Employer to deduct from my salary the amounts set forth below and to deposit these funds in the Credit Union for each payroll period following receipt of the Authorization until further notice from me. If this is a change in a previous Authorization, I instruct my Employer to cancel my previous Authorization and to follow this Authorization. If I fail to cancel this Authorization upon filing for bankruptcy, my Employer and the Credit Union are directed to make and apply deductions in accordance with this Authorization.

Deposit Amount^*:		Net Check Other
If other, please specify:	$

Payroll Period^*:		Weekly Biweekly Monthly Semi-Monthly
Credit Union R/T No. 291378130

Credit Union Direct Deposit Authorization I authorize the Credit Union to apply my payroll deduction for each pay period as follows:

Share Draft/Checking:	$

Share/Savings:	$

Money Market:	$

Loan #:
Amount:	$

Loan 2 #:
Amount:	$

IRA:
Amount:	$

Other:
Amount:	$

Other:
Amount:	$

*Total^:**	$