ࡱ> 7 bjbjUU ;7|7|l$D6w&^}L%%%%%%%$-' M)l%Q}|%c &.%%!!!!R `|+!!;&<w&!))!UFCW LOCAL 1776 FEDERAL CREDIT UNION 3031 A Walton Rd., Suite 310 Plymouth Meeting, PA 19462 (610) 9412604 PAYROLL DEDUCTION DIRECT DEPOSIT AUTHORIZATIONEMPLOYER PAYROLL DEDUCTION AUTHORIZATIONMember:  FORMTEXT       Member Acct. No:  FORMTEXT      Employer:  FORMTEXT      SSN/TIN:  FORMTEXT      Phone Home (  FORMTEXT       )  FORMTEXT       Work (  FORMTEXT       )  FORMTEXT      Payroll No:  FORMTEXT       FORMTEXT       Initial Authorization  FORMTEXT       Change in Authorization I hereby authorize my Employer to deduct from my salary the amounts set forth below and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. If this is 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.Deposit Amount FORMTEXT       Net CheckPayroll Period FORMTEXT       Weekly FORMTEXT       Biweekly FORMTEXT       $  FORMTEXT       FORMTEXT       Monthly FORMTEXT       Semi-MonthlyCredit Union R/T No: 236084476  FORMTEXT       X Signature Effective Date CUNA Mutual Group, 1993, 200428001Custom D1200 Rev. 04/04EMPLOYER COPY  UFCW LOCAL 1776 FEDERAL CREDIT UNION 3031 A Walton Rd., Suite 310 Plymouth Meeting, PA 19462 (610) 9412604 PAYROLL DEDUCTION DIRECT DEPOSIT AUTHORIZATIONEMPLOYER PAYROLL DEDUCTION AUTHORIZATIONMember:  REF Text1   Member Acct. No:  REF Text2  Employer:  REF Text3  SSN/TIN:  REF Text4  Phone Home ( REF Text5   )  REF Text6   Work ( REF Text7   )  REF Text8  Payroll No:  REF Text9   REF Text10   Initial Authorization  REF Text11   Change in Authorization I hereby authorize my Employer to deduct from my salary the amounts set forth below and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. If this is 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.Deposit Amount REF Text12   Net CheckPayroll Period REF Text15   Weekly REF Text16   Biweekly REF Text13   $  REF Text14   REF Text17   Monthly REF Text18   Semi-MonthlyCredit Union R/T No:  REF Text19  236084476X Signature Effective DateCREDIT UNION DIRECT DEPOSIT AUTHORIZATIONBy signing above, I authorize the Credit Union to apply my payroll deduction for each pay period as follows:Share Draft/Checking $ _____________________________Share/Savings$ _____________________________Money Market$ _____________________________Loan #: ___________________$ _____________________________Loan #: ____________________$ _____________________________IRA: ______________________$ _____________________________Other: _____________________$ _____________________________Other: _____________________$ _____________________________TOTAL$ _____________________________ CUNA Mutual Group, 1993, 200428001 Custom D1200 Rev. 04/04 CREDIT UNION COPY  N>"$>@TVXbdz|ʻwgWj5CJOJQJUj 5CJOJQJUj5CJOJQJUCJOJQJfH q j5CJOJQJU5CJOJQJj5CJOJQJU CJOJQJ5CJOJQJ5B*OJQJphB*CJOJQJph5B*CJOJQJph#j5CJOJQJUmHnHu"N$@BDb|$$Ifl4"0L^>+  04 la $$Ifa$ 4$If 4. $If^. 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