Credit Union Payroll Deduction Form or
Distribution of Direct Deposit



Social Security No.


First Name:


Last Name:


Middle Initial:


Company Name:


Company Address:


Work Phone:

I Elect:


Payroll Deduction (Specific amount to Credit Union)

Direct Deposit (Net Pay to Credit Union)

Cancellation

I am paid:


Weekly

Bi-Weekly (every two weeks)

Monthly

Bi-Monthly (15th and last day)


Deduct from my pay each payroll period $__________ to be applied to the accounts as specified in the next section of this form.


Please distribute my deductions in the following manner:

(Use R for remainder of Direct Deposit)


Regular Share Savings (S1)
$____________

Share Draft Checking (S4)
$____________

Vacation Club (S7)
$____________

Christmas Club (S8)
$____________

Money Market Investment (S5)
$____________

IRA Money Management (S2)
$____________

Family Transfer:

Account Number Account Type

To:
____________ ____________ $____________

To:
____________ ____________ $____________



Loan#________________________________....................$_____________

Loan#________________________________....................$_____________

Loan#________________________________....................$_____________