Personal Information

* Indicates Required

• First Name *
• Last Name *
• Employer *
• Social Security Number
• Phone *
• Payroll Number

Authorization

* Indicates Required

• Initial Authorization Change Authorization

  I authorize my employer to deduct from my salary the amounts indicated on this Authorization and to deposit these funds at the bank for each payroll period following receipt of this Authorization until further notice from me. I understand that this Authorization is revocable. If this is a change in a previous Authorization, I instruct my employer to cancel my previous Authorization and to follow this Authorization. I grant the bank 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.

• Deposit Amount *

  Net Check Other
• Payroll Period *

  Weekly BiWeekly Monthly Semi-Monthly
• Deposit To *

  Savings Checking
• Account Number *
• Effective Date *

Disbursement