This form will help you enroll in direct deposit with a

This form will help you enroll in direct deposit with a new or additional employer.

ALL DATA MUST BE GOMPLETED FirstName:

I request thatmyemployer direct deposit mypay.I hereby authorize myemployer to initiate credit entries formynetpayto myMoney Network card,issued byMetaBank. lf fundsto which I amnotentiiled

LastName: Street Address:

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q r r n hfunds. e n d return r e t r r r n of n f such frrnrlq T h i c authority e r r t h n r i t r is irc to t n remain r o m r i n in in o f f o n runtil r r n t i lmy m' and This effect employer or MetaBank hasreceived written notification frommeof its termination insuchtimeandsuchmanner asto afford myemployel andMetaBank a reasonable opportunity to actonit oruntilMetaBank cancels myCard. lacknowledge thattheorigination ofentries.to my Cardmustcomply withtheprovisions of U.S.law.

Signature E m p l o y leDeN u m b e r Date

100% of paycheck other % of paycheck set amount $________

______%

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Date of Birth:(month) (day) (year) -ABARouting Transit Number: 073972181 ** CardAccount #:_________________ Account type:Checking

Privileged andconfidential information is contained inthisdocumen Donotcopyor deliver thisinformation to anyone other thanyour employer. Pavroll Department: Setting upthisdirectdeposit doesnotrequire pre-noting. lf youhave anyquestions about thisdirect deposit please enrollment call1-866-387-5146.

** Your Card Checking Account Number is on the Direct Deposit form that comes in your card package. The Card Account Number is not the same number that appears on your prepaid debit card. If you cannot locate the Card Account Number, call Customer Service at 1-866-387-5146 for assistance.

Follow the instructions and return to your employer