EPB Form 3

EPB EMPLOYEE'S AUTHORIZATION
Please print, fill out, sign and return to the Payroll Department

Courtesy of
EPBECU
Form 3

I authorize you and the financial institution(s) listed below to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my account(s) each pay period. This authority will remain in effect until I have cancelled it in writing.

**Account 1**
Draft (Checking) Account or Share (Savings) Account	$_________ Amount of Pay to Deposit

EPB Employees Credit Union
Financial Institution

1500 McCallie Avenue
Branch

Chattanooga
City

__________________________________
Name (Please Print)

Tennessee
State

2 6 1 3 8 8 5 0 3
Routing Transit Number

____ ____ ____ ____ ____
Credit Union Account Number

**Account 2**
Draft (Checking) Account or Share (Savings) Account	XXXX Remainder of Pay to Deposit

__________________________________
Financial Institution

__________________________________
Branch

__________________________________
City

__________________________________
Name

__________________________________
Account Number

__________________________________
State

__ __ __ __ __ __ __ __ __
Routing Transit Number

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Account Number

[BE SURE TO DATE AND SIGN THIS FORM]

__________________________________
Date

__________________________________
Signature