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EMPLOYER PAYROLL DEDUCTION AUTHORIZATION
MEMBER MEMBER ACCT #
HOME PHONE PAYROLL #
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.
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 $
MONEY MARKET $
LOAN 1 # $
LOAN 2 # $
OTHER 1 $
OTHER 2 $