Direct
Deposit
Sign-Up
Form
Complete sections 1 and 2
on
the form below.
For paychecks, take the completed form to your payroll
department. For non-paychecks, mail the form to the
company or agency you have listed
in
section
2.
(1099A Forms
are
available upon request.)
SECTION
#1
A NAME
OF
PAYEE (last, first, middle initial)
ADDRESS (street, route,
PO.
Box
, APO/FPO)
CITY
STATE ZIP
TELEPHONE NUMBER
( )
B NAME
OF
PERSON(S) ENTITLED
TO
PAYMENT
c CLAIM
OR
PAYROLL ID NUMBER (printed
on
Government Check)
PREFIX: SUFFIX:
D TYPE
OF
DEPOSITOR ACCOUNT D CHECKING D SAVINGS
E DEPOSITOR ACCOUNT NUMBER
F TYPE OF PAYMENT (check
one;
more
than
one
requires a separate
fo
rm)
D Company Payroll
D VA Compensation or Pension
D Social Security D Fed. Salary I Mil. Civilian Pay
D Supplemental Security Income
D Mil. Active
_______
_
D Railroad Retirement
D Mil. Retired
_______
_
D Civil Service Retirement (OPM)
D Mil. Survivor
______
_
G THIS SECTION FOR ALLOTMENT OF PAYMENT ONLY
TYPE: AMOUNT:
I certify that I
am
entitled to the payment identified above. In signi
ng
this form,
I authorize
my
payment to be sent to VyStar Credit Union.
SIGNATURE: DATE:
SECTION
#2
COMPANY OR GOVERNMENT AGENCY NAME
COMPANY OR GOVERNMENT AGENCY ADDRESS
SECTION
#3
NAME, ADDRESS AND PHONE NUMBER
OF
FINANCIAL INSTITUTION:
VYSTAR
CREDIT
UNION
• P.O.
BOX
45085
JACKSONVILLE,
FL
32232-5085
(904)
777-6000
OR
800-445-6289
ROUTING NUMBER: CHECK DIGIT:
2 6 3 0 7 9 2 7 6
