Print 2 copies of this form. Turn one into your employer, and retain one for your own records.

  Millard County Credit Union 
  PO Box 185 
  Delta , UT 84624

PAYROLL DEDUCTION REQUEST 
TO Millard County Credit Union
Phone 435-864-4411 Routing #: 324377024
 
Employee's Name & Address: 
 
 
 		 Social Security Number: 
__ __ __ - __ __ - __ __ __ __
Employer's Name & Address: 
 
 
 		 Telephone: 
Home:  __ __ __ - __ __ __ __ 
Work:  __ __ __ - __ __ __ __
Account Number: 
0 0 0 __ __ __ __ __ __ __
(For Example: If your account # is 12345-6, the number should be 0000123456)
 
 
TOTAL AMOUNT OF DEDUCTION per pay period to  __ SAVINGS  or  __ CHECKING (check one):      $___________ 
The stated amount will be deposited to the specified account when received from your payroll.

 

I hereby authorize my employer to (check one)  __ START,  __ CHANGE,  __ CANCEL deductions from salaries or wages due to me in the amount specified above which are for remittance to Millard County Credit Union, box 185, Delta , UT 84624 for credit to my account.

 


Employee's Signature ______________________________   Date ___________