University Health FCU
Main Office Fax: 706.774.4860
Martinez Branch Fax: 706.854.1466

DIRECT DEPOSIT/
PAYROLL DEDUCTION
AUTHORIZATION
Member 
Employer    
Home Phone   Work Phone
Member No:
SSN/TIN:    

Payroll No:  

Initial Authorization
Change in Authorization

I hereby authorize my employer to deduct from my salary the amounts set forth in this Authorization and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. I understand that this Authorization is revocable. If this a change in a previous Authorization, I instruct my employer to cancel my previous Authorization and to follow this Authorization. If I fail to cancel this Authorization upon filing for bankruptcy, my employer and the Credit Union are directed to make and apply deductions in accordance with this Authorization. I grant the Credit Union a power of attorney to increase or decrease the amount of my deduction upon my written or verbal request. This power of attorney only applies to a loan or credit extension for which the payment may vary. I authorize my employer to honor any payment change made under this power of attorney.

Deposit Amount: Net Check      $__________________

Credit Union R/T No: ___________________________________

Deposit to Savings       Account No:___________

Payroll Period
Weekly
Biweekly
Monthly
Semi-Monthly

   _______________________________________
   Signature
                                Customer Copy

   ________________
   Effective Date
You Must Print, Sign, and Return to Credit Union
(by mail, fax or in person)
A signature is needed to complete the process