Payroll Deduction Form Please Enter Your Email Address: Applicant: Name: Account #: Soc Sec. #: Employer Name/Division: Employer Address: Employer Phone #: Total Deduction Amount: $ Distribution: Account # Share type/Loan # Amount $ $ $ $ $ $ By pressing the submit button I authorize my employer to deduct the amount I have specified and send it to the credit union for distribution as I have instructed. I reserve the right to stop or change this deduction at anytime without notice to the credit union.

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hfcu@hanoverfcu.org
Last Updated: September 16, 1999