Fillable INITIAL CHANGE CANCEL/REVOKE

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INITIAL CHANGE CANCEL/REVOKE

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DIRECTDEPOSIT
AUTHORIZATION
PLEASESELECTAUTHORIZATIONTYPE:
□ INITIAL □ CHANGE □ CANCEL/REVOKE
EMPLOYERINFORMATION
EMPLOYERNAME: EMPLOYERTELEPHONE:
EMPLOYEE/MEMBERINFORMATION
MEMBERNAME(LAST): (FIRST): (M.I.): SOCIALSECURITYNUMBER:
CURRENTADDRESS: APTNO.:
CITY: STATE: ZIPCODE:
OTHERCONTACTINFORMATION
EMAILADDRESS: TELEPHONE(HOME): TELEPHONE(OTHER):
PAYROLLDEDUCTIONSPECIFICS
ACCOUNTTYPE: DEPOSITAMOUNT:
□
NETCHECK
□
PAYROLLPERIOD:
□
WEEKLY □ BI‐WEEKLY □ SEMI‐MONTHLY
□MONTHLY □OTHER:___________________
ACCOUNTNUMBER:
OURROUTING/TRANSITNUMBER: 313083837
$
I hereby authorize my employer, as indicated above, todeduct frommy salary theamounts as set forth in this
authorization.MyemployerisfurtherinstructedtodepositthesefundsatI.B.E.W.LU66FederalCreditUnionfor
eachpayrollperiodfollowingthereceiptofthisauthorization.Thisdeductionistoremainineffectuntilsuchtime
asitischangedorrevokedbymyauthorization.Ifthisisachangeofapreviousauthorization,Iinstructmyemployer
toamendmypreviousauthorizationandtofollowthisauthorization.
X_______________________Date:__________
4345ALLENGENOAROAD|PASADENA,TEXAS77504
(713)946‐6513|(713)946‐1939Facsimile
www.MyCU66.org
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INITIAL CHANGE CANCELREVOKE

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Completed 10 August 2021

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