Authorization To Change Deductions

Please complete the form below if your credit union account is already enrolled in Direct Deposit.

*Indicates a required field.
 

First Name	*
M.I.
Last Name	*
Record Type [1-2]:                                     3 C
Employee Number [3-8]	*
Social Security Number [9-18]	*
Email Address	Please provide if you would like email notification of form submission.
Check One Box: * Change Deduction Discontinue Deduction
DISTRIBUTION: Please distribute my total deduction accordingly: *Enter 0.00 for discontinued deductions.
Share Savings (Suffix A)
Share Checking (Suffix 0)
Holiday Club
Vacation Club
Loan
Loan 2
Loan 3
TOTAL DEDUCTION	* This is an automated field equal to the sum of the amounts entered above.
DEDUCTION AMOUNT: I hereby request the Total Deduction amount (minimum $5.00) above be deducted from my salary or sick pay benefits every payday for deposit to my credit union shares as allocated above. * Yes, I agree to the above entered allocations and agreement.
ELECTRONIC FORM SUBMISSION AGREEMENT: By submitting this form I am verifying the following: 1. The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the transaction requested above. 2. I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union. 3. I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval. 4. By entering my first and last name next to the Electronic Signature field, this stands as the equivalent of a handwritten signature. Therefore, the same laws and regulations regarding forgery apply. * Yes, I agree to the terms and conditions of submitting this form Electronically as outlined in the guidelines above.
Electronic Signature (Print First & Last Name) *
Date *
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