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Personal Information
Authorization
Disbursement
  • Personal Information

  • Authorization

    • Authorization Type *
    • I authorize my employer to deduct from my salary the amounts indicated on this authorization and to deposit these funds at Client Name for each payroll period following receipt of this authorization until further notice from me. I understand that this authorization is revocable. If this is a change in a previous authorization, I instruct my employer to cancel my previous authorization and to follow this authorization. I grant Client Name 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 *
    • Payroll Period *
    • Deposit To *
  • Disbursement

    Share Draft/Checking
  • Share/Savings
  • Money Market
  • Loan
  • Loan
  • Loan
  • IRA
  • Other:
  • Other:
  •   TOTAL

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