Hoosier Hills Credit Union - Payroll Deduction Form

Payroll Deduction Form

Please fill out this form, print it, sign it below, and mail to: Hoosier Hills Credit Union 630 Lincoln Avenue Bedford, IN 47421 Click for HHCU's Privacy Policy.
Member Number
Member Name
Address
City, State, Zip
Social Security Number
Employer (Only the employers in this list offer payroll deduction.)
I want to start payroll deduction change my payroll deduction cancel my payroll deduction
* Employee must initiate contact with employer to begin payroll deduction process. I hereby request my employer (as indicated above) to forward funds from my pay, in the amount(s) indicated below, to my account(s) with Hoosier Hills Credit Union: Entire Paycheck (if your employer offers this service) Deduction Amount $
Please indicate below, how you would like these funds distributed within your account.
Checking	$	Money Market	$
Savings	$	Loan	$
Christmas Club	$	Other (specify what account)	$
Vacation Club	$
I understand that if a specific amount to be deducted from my pay is indicated above, or if I have indicated for my entire paycheck to be deposited into the Credit Union, it will be deposited to the Regular Savings Account, unless I have requested the Credit Union accounts as indicated above. This authorization will remain in effect until canceled by me in writing on a similar form.
Name __________________________________________ Date_______________________ The signature must be the owner of the payroll check. All signatures will be verified before request is accepted.