Direct Deposit/Payroll Deduction Form

EMPLOYER PAYROLL DEDUCTION AUTHORIZATION

MEMBER MEMBER ACCT #

EMPLOYER

HOME PHONE PAYROLL #

WORK PHONE

I hereby authorize my Employer to deduct from my salary the amounts set forth below and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. If this is a charge in a previous 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 AMOUNT $

CREDIT UNION R/T NO. EFFECTIVE DATE

By checking this box and submitting this application electronically, I agree to the same terms that apply to a signed application.

CREDIT UNION DIRECT DEPOSIT AUTHORIZATION

By checking the box above, I authorize the Credit Union to apply my payroll deduction for each pay period as follows:

SHARE DRAFT/CHECKING $

SHARE/SAVINGS $

MONEY MARKET $

LOAN 1 # $

LOAN 2 # $

IRA $

OTHER 1 $

OTHER 2 $

TOTAL $