Members United Credit Union

DIRECT DEPOSIT FORM

ACCOUNT NUMBER

DATE

NAME

SSN

MEMBERS UNITED CREDIT UION

ROUTING #

TO EMPLOYER:

PAYROLL NUMBER:

I hereby authorize you to deduct the following from my pay until further notice, and transmit to the above named Credit Union.

TOTAL DEDUCTION

EFFECTIVE DATE

CREDIT UNION EMPLOYEE

MONTHLY	SEMIMONTHLY	BIWEEKLY	WEEKLY
NEW	CHANGE	STOP	REALLOCATE

Signature of Employee__________________________________

Phone: 706-323-2721 Fax: 706-323-4589