DIRECT DEPOSIT/PAYROLL DEDUCTION AUTHORIZATION
Member 
Employer    
Home Phone   Work Phone
Member No:
SSN/TIN:    
Payroll No:  

Initial Authorization
Change in Authorization

I hereby authorize my employer to deduct from my salary the amounts set forth in this Authorization and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. I understand that this Authorization is revocable. If there is a change in a previous Authorization, I instruct my employer to cancel my previous Authorization and to follow this Authorization. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In the event that Company deposits funds erroneously into my account. I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit.

This authorization is to remain in full force and effect until Company and Bank have received written notice from me of its termination in such time and in such manner as to afford Company and Bank reasonable opportunity to act on it.


Bank Name   City

Deposit Amount: Net Check      $__________________

Credit Union R/T No: ___________________________________

Deposit to Savings       Checking
Account No:___________

State Zip
Payroll Period
Weekly
Biweekly
Monthly
Semi-Monthly

   _______________________________________
   Signature                                Member Copy

   ________________
   Effective Date
You Must Print, Sign, and Return to Your Employer
(by mail, fax or in person)
A signature is needed to complete the process