Payroll Distribution Authorization

* Required Fields

In order to set up payroll distribution, you must first set up direct deposit with your employer through one of the following:

Sign up at your payroll or human resources office.
If your employer participates, sign up at Employee Express.
For Social Security direct deposit, sign up at Go Direct.

Our routing number is 254074222.

NEW Payroll DistributionCHANGE Payroll DistributionCANCEL Payroll Distribution

If this is a change to current payroll distribution, please enter the OLD total distribution:

Total Current Deduction Each Paycheck:

Distributed as follows:

Account Number: * Account type: * Amount: *

Member Information

Email Address: * Member Number: *

First Name: *

Middle Initial:

Last Name: *

Street Address: *

City: * State: * Zip: *

Social Security Number: *

Employer: *

Work Phone:

Home Phone: *

Cell Phone:

Additional Remarks:

Member Signature:*

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Payroll Distribution Authorization

Distributed as follows:

Member Information

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Payroll Distribution Authorization

Distributed as follows:

Member Information

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