Direct Deposit/Payroll Deduction

Initial Authorization

Change in Authorization

Cancel Authorization

Applicant's First Name

Last Name

SSN/TIN #

Account Number

Home Phone #

Employer

Direct Deposit & Payroll Deduction Authorization

Deposit

Net Check

Specified Amount*

Amount $*

Payroll Period

Weekly

Bi-Weekly

Semi-Monthly

Monthly

Deposit To Account Details

Share Savings #

Trailer/Suffix #

Share Draft Checking #

Trailer/Suffix #

Other Account#

Trailer/Suffix #

Other Account#

Trailer/Suffix #

Other Account#

Trailer/Suffix #

Loan #

Trailer/Suffix #

Loan #

Trailer/Suffix #

Finishing Up

Please select the location you want this authorization directed to.

Brook Park Branch - 5681 Smith Road Brook Park, OH 44142

Highland Heights Branch - 390 Alpha Park Highland Heights, OH 44143

Walton Hills Branch - 21375 Alexander Road Walton Hills, OH 44146

Signature

I hereby grant Best Reward Federal 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)

Prior to submitting this application, please enter the answer in the text box below

Is one > than two? (true/false)

Direct Deposit/Payroll Deduction

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