Direct Deposit Form

Member Name *
Member Name
Phone *
Work Phone *
Work Phone
Authorization Type *
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 this 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. I grant the Credit Union a power of attorney to increase or decrease the amount of my deduction upon my written or verbal request. This power of attorney only applies to a loan or credit extension for which the payment may vary. I authorize my employer to honor any payment change made under this power of attorney.
Net Check or Dollar Amount
Payroll Period *
Deposit to: *
Effective Date *
Effective Date