Please review and complete the following information.
Return this form to your employer's HR office.

Section 1 - Direct Deposit Authorization

Name:

Social Security Number:

Address:

Company Name:

Company Address:

Deposit entire amount to checking account #

Deposit $ to savings account #

      and remaining into checking acct #

Credit Union Name: POWERCO Credit Union - Routing # 244077093
Credit Union Address: 471 Morrison Road, Suite M, Gahanna, OH 43230

I authorize:

• Above listed entity to initiate deposit of my funds to my POWERCO Credit Union checking or savings account
• POWERCO Credit Union to credit entries to my account(s)
• This authorization to remain in effect until I send written notice of change or cancellation

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Signature