Direct Deposit Enrollment Form - Urw
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1DIRECT DEPOSIT ENROLLMENT FORM
(Forward completed form to your payroll office or any other organization that regularly sends you a payment.)
INITIAL AUTHORIZATION CHANGE IN AUTHORIZATION
1. MEMBER INFORMATION
LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
2. EMPLOYER/COMPANY/ORGANIZATION’S INFORMATION
EMPLOYER/COMPANY/ORGANIZATION
EMPLOYER NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
3. ACCOUNT INFORMATION
DEPOSITORY NAME
ROUTING/TRANSIT NUMBER
URW COMMUNITY FEDERAL CREDIT UNION
251480482
PRIMARY ACCOUNT
ACCOUNT NUMBER
AMOUNT OF DEPOSIT
CHECKING
SAVINGS
NET PAY
OTHER $
SECONDARY ACCOUNT
ACCOUNT NUMBER
AMOUNT OF DEPOSIT
CHECKING
SAVINGS
NET PAY
OTHER $
5. AUTHORIZATION
I hereby authorize the above Employer/Company/Organization to initiate deposit of my funds to my URWFCU account(s).
This authorization will remain in effect until I provide written notice of change or cancellation of this direct deposit.
SIGNATURE
DATE
4. DISTRIBUTIONS (For Credit Union’s Use)
Total Deductions: $ _ ___________________
Effective Date: _______________________
ADD/CHANGE DELETE
01 $__________
LN ____ $__________
01 $__________
LN ____ $__________
02 $__________
LN ____ $__________
02 $__________
LN ____ $__________
03 $__________
LN ____ $__________
03 $__________
LN ____ $__________
04 $__________
LN ____ $__________
04 $__________
LN ____ $__________
05 $__________
LN ____ $__________
05 $__________
LN ____ $__________
06 $__________
LN ____ $__________
06 $__________
LN ____ $__________
IRA_____ $__________
LN ____ $__________
IRA_____ $__________
LN ____ $__________
Recipient Info Recipient Info
Member #
S or L
ID
Amount
Member #
S or L
ID
Amount
___________
_____ _____
_________
___________ _____ _____ _________
___________
_____ _____
_________
___________ _____ _____ _________
___________
_____ _____
_________
___________ _____ _____ _________
___________
_____ _____
_________
___________ _____ _____ _________
Member’s Signature _______________________________________ Employee’s Initials _________________________
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