EPBRetireeForm

EPB RETIREE'S AUTHORIZATION
Please fill out and sign, attach a voided check or deposit slip for verification of all financial institution information and return to the Payroll Department.

Courtesy of
EPBECU
Retiree Form

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

**Account 1**
Draft (Checking) Account or Share (Savings) Account	100 Percent of Amount 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

__________________________________
Date

__________________________________
Signature

__________________________________
Phone Number

[BE SURE TO DATE AND SIGN THIS FORM]