I hereby authorize my employer to deduct from my earnings, the amount indicated below, to be transmitted to the WVU Employees' Federal Credit Union and applied to my account as I have authorized the credit union below. I also hereby authorize the WVU Employees' Federal Credit Union to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account.

I understand the deductions will be made on a continuing basis from my pay beginning with the pay period following receipt of authorization by my payroll office or state auditor's office.

I further understand I may revoke this authorization at any time by filling out a written request with the WVU Employees' Federal Credit Union office. The revocation will become effective the pay period following receipt of the written notice.

SOCIAL SECURITY NUMBER : ____________________________
LAST NAME : _________________________________________ INITIALS _____-_____
I WORK AT : ( Please Check ) WVU_____ : WVU Hospital _____ : UHA _____

SAVINGS Per pay period $________.____
LOANS Per pay periob $________.____
SHARE DRAFT Per pay period $________.____ ( Checking )
CHRISTMAS CLUB Per pay period $________.____
OTHER Per pay period $________.____
TOTAL DEDUCTIONS Per pay period $________.____
Customer Account Number #_____________________

EMPLOYEE SIGNATURE:_________________________________DATE :___________
TRANSIT/ABA# 251579102