Authorization for Payroll Deduction

Member Name
Member Account Number
Company Name
Location
Code
Payroll Number
Type or Change in Deduction (Choose One)	Start Change Stop
Pay Frequency (Choose One)	Weekly Bi-Weekly Semi-Monthly Monthly
Notice: By completing this form you are changing the total amount to be deducted from your paycheck and/or the distribution of that deduction into each of your various credit union products. Please review the distributions shown at the bottom of this form to insure that your deduction will be split into your products correctly. By transmission ofthis document you are authorizing your employer to deduct the total amount shown at the bottom of this form from each of you subsequent paychecks, until you stop or change your deduction.
*For loan payments, divide the amount of the monthly payment by the number of paychecks in each month. The amount deducted will be deposited into savings or checking and then transferred when the loan payment is due. All automatic payments via payroll deduction stop if member submitting this form any petition under U.S.C 701.
Deduction Breakdown
Type of Account	Amt.of Deduction Each Payday
Savings	(1)$
	(2)$
Checking	(1)$
	(2)$
Christmas Club	$
Vacation Club	$
Loan Payment *See Above Note	$
	$
Money Market	$
IRA	$
IRA Type	Regular Roth Education
Total to be deducted from EACH paycheck	$

Click here to download the application