Name _____________________  
Credit Union Member No.______________________


Soc. Sec. No. _____________________________
Name of Company _____________________________________________
Company Address______________________________________________
For Company Payroll and Direct Deposit, our ABA Routing Number is 211081892.

I hereby authorize you as follows:
Deduct each payroll period $___________Dollars from my pay and transmit same to New England Teamsters Federal Credit Union until further notice.

Credit Union:
Please distribute payroll deduction as follows:
$________________ to Share (Savings) Account
$________________ to Share Draft (Checking) Account
$________________ other

Change my Credit Union deduction from
$__________ to $ __________ from my pay, each payroll period, and transmit same to New England Teamsters Federal Credit Union until further notice.

Credit Union:
Please distribute payroll deduction as follows:
$________________ to Share (Savings) Account
$________________ to Share Draft (Checking) Account
$________________ other

Cancel my Credit Union deduction in the amount of $ __________

Date_______

 Signature of Employee (Required)________________________________

EACH MEMBER ACCOUNT INSURED UP TO $100,000 BY NATIONAL CREDIT UNION ADMINISTRATION

Instructions:
Please print this form.

Complete all sections, sign, and mail to:

New England Teamsters Federal Credit Union
P. O. Box 1498
Arlington, MA 02474