Payroll Choices Election Form

Payroll “Choices” Election Form

Associate Name (print) ______Employment Location # ______

Address ______

Telephone Numbers (home) ______(work) ______Social Security Number ______

Select “Balance of Pay” for your primary account, and if electing an additional account, provide a “Specific dollar amount.”

Option 1: Complete for Direct Deposit Choice Employer will pay all, or a portion, of my net pay as selected below into the account at the financial institution I have provided.

I would like my wages/salary deposited to the following bank account (s)

Bank Account #1 Checking Savings Bank Account #2 Checking Savings

(attach a voided check or complete information) (attach a voided check or complete information)

Bank Name ______Bank Name ______

Routing Number ______Routing Number ______

Account Number ______Account Number ______

I wish to deposit (check one): I wish to deposit (check one):

Balance of pay Balance of pay

Specific dollar amount $ ______.00 Specific dollar amount $ ______.00

Direct Deposit Option 2: Complete for Money Network Service Employer will pay all, or a portion, of my net pay as selected below using the Money Network Service, and I may use either of the following options:

Money Network Check. The Money Network Check is a paycheck I can complete on or after each payday. It can be deposited into my personal bank account or cashed for free at Money Network check-cashing partners.

Money Network Payroll Debit Card. The Money Network Payroll Debit Card provides a dependable, safe, optional, and convenient way to receive and access my pay on and after each payday with the following features: immediate access wherever the Card is accepted for ATM cash withdrawals, bank-branch withdrawals, and store purchases (including “cash back”); money transfers to a personal or joint checking account; free balance inquires by phone or online. There is no monthly service charge for the Card as long as I am employed by Stein Mart. Many Card transactions are free (and I need never incur a fee to access 100% of my wages using the Service), but there are fees for other transactions. The Terms and Conditions, fee schedule, and other disclosures related to the Service are included in the Service’s Welcome Packet. Once I have consented to those terms and activated my Service account, I may begin to use the Service.

I would like my wages/salary deposited to my Money Network Account. I understand I can receive all of my pay in full without cost each pay period by using a Money Network check. I also understand there is no fee for Point of Sale (POS) purchases. This program may include per use fees including $1.75 for non-network ATM withdrawals and ATM balance inquiries and declines, $6.00 card replacement, or optional $2.95 monthly paper statement and additional card for $2.00.

I wish to deposit (check one): Balance of pay Specific dollar amount $ ______.00

Payroll Authorization

I understand my paycheck information will be delivered electronically via secure online access or Interactive Voice Response (IVR). I understand if no payroll choice is made within 30 days my pay will be delivered through the payroll debit card. I understand the Money Network Card does not provide access to a savings or checking account. I understand I have the right to change the method of receiving wages at any time.

Signature of Associate ______Date ______

Signature of Parent/Guardian (if associate is under 18 years of age) ______Date ______