Authorization for Direct Deposit

To initiate direct deposit to your account at Blackhawk Community Credit Union please provide the completed the form to your payroll office or company sending the deposit. I wish to send my NET direct deposit to: Blackhawk Community Credit Union 2640 W. Court Street Janesville, WI 53547 Routing #275978048

Employee Name: Social Security #: BHCCU Account #: Deposit to my: Savings Account  Checking Account

Employer/Payroll Office: Total Deposit Amount: $

Member Signature: ______

Date:______

I authorize the above listed employer/payroll office to initatite direct deposit in the amount listed above to Blackhawk Community Credit Union account. This Authority is to remain in full force and effect until my employer/payroll office has received written notification from me of its termination. I understand that it is my responsibility to notify my payroll office if any of the above information changes.