Direct Deposit Form Tell us about you Initial AuthorizationChange in AuthorizationCancel Authorization Applicant's First Name Last Name SSN/TIN # Account Number Home Phone # Email Employer () -Second partThird part Direct Deposit & Payroll Deduction Authorization Deposit Net CheckSpecified Amount* Amount $* Payroll Period WeeklyBi-WeeklySemi-MonthlyMonthly Deposit To Account Details Share Savings # Trailer/Suffix # $ Share Draft Checking # Trailer/Suffix # $ Loan # Trailer/Suffix # $ Loan # Trailer/Suffix # $ Other Account# Trailer/Suffix # $ Other Account# Trailer/Suffix # $ Other Account# Trailer/Suffix # $ Total $ Signature I hereby grant Mill Town Credit Union the authority to increase or decrease the amount of deposits and/or deductions or change my distribution of deposits and/or deductions upon my written request as specified on this form. Applicant's Signature Date (mm/dd/yyyy) Please enter the security code below