Direct Deposit Enrollment Page 2
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4Direct Deposit Enrollment
New Request
Change Request
Use this form to notify your employer (or any other non-governmental organization that regularly sends a payment
to you) that you want the proceeds deposited directly into the Trona Valley Community FCU accounts specified
below.
Name
Social Security Number
Address
City
State
Zip
I hereby authorize (company/organization)
, hereinafter called “Originator”, to
initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit error to my
account(s) indicated below and the depository institution named below, hereinafter called “Depository”, to credit
and/or debit the same to such account.
PRIMARY ACCOUNT
Depository Name (Bank)
Account Type
Checking
Savings
Trona Valley FCU
840 Hitching Post Drive
Account No.
Green River WY 82935 1-307-875-9800
Routing Number
Amount to Deposit
Net pay
$__________ (fixed amount)
302 386 765
If the Originator allows direct deposit to more than one account, I elect to have part of my proceeds put into the
following account:
OPTIONAL SECONDARY ACCOUNT
Depository Name (Name/Address)
Account Type
Checking Savings
_______________________________
_______________________________
Account No.________________________
Routing Number
Amount to Deposit
Net pay
_________________
$
(fixed amount)
This authority is to remain in full force and effect until Originator has received written notification from me of its
termination in such time and in such manner as to afford Originator and Depository a reasonable opportunity to
act on
Signature__________________________________________________Date_______________
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