Migizi Direct Deposit Election Form

Direct Deposit Electronic Wage Payment Election and Consent Form

First Name

Middle Initial

Last Name

Date of Birth (mm/dd/yyyy)

Date

Social Security Number

Your social security has 9 numbers

Employee ID

Legal Address (No PO Box)

Apt # (if applicable)

City

State

Zip Code

Home Phone

Mobile Phone

Email

example@example.com

Mailing Address (optional)

City

State

Zip Code

Home Phone Number

Please enter a valid phone number.

Mobile Phone Number

Please enter a valid phone number.

Email Address

example@example.com

WAGE PAYMENT ELECTION

Direct Deposit (indicate amount of deposit to each account type and provide account number)Wisely® Pay card by ADP

Direct Deposit #1

Indicate amount of deposit % to account

Direct Deposit #1

CheckingSavings

Bank Routing number for Direct Deposit #1

Account number for Direct Deposit #1

Direct Deposit #2

Indicate amount of deposit % to account

Direct Deposit #2

CheckingSavings

Bank Routing number for Direct Deposit #2

Account number for Direct Deposit #2

Direct Deposit #3

Indicate amount of deposit % to account

Type a question

CheckingSavings

Bank Routing number for Direct Deposit #3

Account number for Direct Deposit #3

Wisely Pay card by ADP (indicate amount of deposit) You must check one box

Full Deposit: I want to receive 100% of my full net pay on my Wisely Pay card every paydayPartial Deposit: See below for furtheri nstructions

For partial deposit, I want to receive % of my full net pay on my Wisely Pay card every payday.

I confirm my authorization to be paid through the Wisely Pay card is fully voluntary. I acknowledge I have received and read the Wisely Pay card Fee Schedule, Cardholder Agreement, and Privacy Notice. I understand that in order to use the Wisely Pay card, I will need to accept and agree to the Cardholder Agreement and to pay the fees as indicated on the Fee Schedule by activating my Wisely Pay card. By electing Wisely Pay card as my wage payment choice, I am consenting to provide my personal information to ADP to enroll in and request a Wisely Pay card. IMPORTANT INFORMATION ABOUT APPLYING FOR A NEW PREPAID CARD ACCOUNT - To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open a Prepaid Card account, ADP may require your name, address, date of birth, Social Security number, tax identification number and other information that will allow ADP to identify you. ADP may also ask to see your driver's license or other identifying documents. You will not be subject to a credit check.

Paper Check - Please note this option is not encouraged due to the inconvenience to you, the possibility of lost or stolen checks and additional expenses. An employer can pay employees by direct deposit, so long as the employee has not objected in writing to payment by direct deposit. Minnesota Stat. 177.23.

You may make arrangements to receive your pay by paper check. Please contact your supervisor to make arrangements with the accounting department to receive a paper check through a bill payment service, Paychex payroll processing or another agreed upon form of a paper check.

I authorize my employer or its payroll service provider, Paychex to initiate credit entries each pay date to deposit my pay (either net or a portion thereof) into the checking, savings or Wisely Pay card account selected in this election and consent form. If funds to which I am not entitled are deposited to my Account, I authorize my employer or Paychex to initiate any action to reverse or correct an erroneous credit entry to my Account and to direct the bank to return said funds to my employer either directly or through Paychex, to the extent permitted by applicable law. I will review my pay statement to ensure that my wages are being deposited correctly into my Account each payroll period. I understand that I can change my election at any time by contacting my employer and that this authorization replaces any previous authorizations and will remain in full force and effect until my employer or Paychex has received written notification from me of its termination and my employer or Paychex and the bank has had a reasonable opportunity to act on said termination.

CONSENT TO ELECTRONIC PAY STATEMENTS

I agree to receive and access all of my pay statements on or before each regular pay day electronically on the Paychex.com, a secure website, rather than receiving a paper statement, until I withdraw my consent. I understand that I may retain a copy of the pay statement by saving it to my computer or by printing a hard copy of it. I understand that I should not save my statement to a public computer as others may see my statement.

For Paper Checks (if not doing Direct Deposit or Wisely Pay Card)

Please note this option is not encouraged due to the inconvenience to you, the possibility of lost or stolen checks and additional expenses. An employer can pay employees by direct deposit, so long as the employee has not objected in writing to payment by direct deposit. Minnesota Stat. 177.23.

Employee Signature

Date

If you chose, Wisely® Pay card by ADP(indicate amount of deposit)