Authorization For Direct Deposit Form

AUTHORIZATION FOR DIRECT DEPOSIT

I authorize AFSCME Council 5 and the Financial Institution listed below, to initiate deposits of funds, to which I am entitled, automatically into my account. If funds to which I am not entitled are deposited to my account, I authorize you to initiate debit entries and adjustments to return said funds. This authority will remain in effect until I have cancelled it in writing at such time and in such manner as to afford you a reasonable opportunity to act.

Date______________ Local #_______________

Name______________________________

Address___________________________

___________________________

Work #_____________________________

Bank_______________________________

Route Number_______________________

Account Number_____________________

Checking _______ Savings_________

X__________________________________

**Please attach a voided check. If requesting a deposit to your savings account please call your banking institution and verify the bank transit rounting number for your savings account.

Any changes with your bank account that will affect your direct deposit; Please notify Laureen Karnick @ (651) 287-0519 or laureen.karnick@afscmemn.org ASAP so all transations transfer correctly.

Please list your e-mail address for future direct deposit pay stub notification ___________________________.

Mail to:		Bob Christensen
		19732 Goldfinch Dr., Farmington, MN 55024