EMPLOYEE DIRECT DEPOSIT AUTHORIZATION

Employee Name / Nombre del empleado*

Address / Dirección

Effective Date / Fecha de vigencia*

Date

Birth date / Fecha de nacimiento*

Date

City State Zip*

Email*

example@example.com

Social Security Number / Número de Seguro Social*

Phone / Teléfono*

Choose Your Method of Direct Deposit / ELIJA SU MÉTODO DE DEPÓSITO DIRECTO

I request my payroll deduction / direct deposit be placed in the following account(s) Solicito que mi deducción de nómina / depósito directo se coloque en la(s) siguiente(s) cuenta(s

Bank / Credit Union / Banco / Cooperativa de crédito

Bank Account Number / Número de cuenta

Routing Number / Numero de ruta

rapid! PayCard Issuance Authorization Form / Formulario de autorización de emisión de rapid! PayCard

I am requesting a rapid pay card /

Financial Institution Name: MetaBank®

124085244 Routing Number: Direct Deposit Account Number: 353 To be assigned and entered by YOUR COMPANY

(Card ID on front of envelope)

The rapid! PayCard® Visa® Prepaid card is issued by MetaBank, Member FDIC, pursuant to a license from Visa U.S.A. Inc. rapid! 4267 5200 1234 7828 1/19DEBITImportant Information for opening a Card account: To help the federal government fight the funding of terrorism and money laundering activities, the USA PATRIOT Act requires all financial institutions and their third parties to obtain, verify, and record information that identifies each person who opens a Card account. What this means for you: When you open a Card account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

I authorize YOUR COMPANY to withhold the indicated amount(s), if available, from my pay, and deposit directly into the account(s) shown and/or I hereby authorize YOUR COMPANY to assign a rapid! PayCard and initiate credit entries and any correcting entries to my assigned rapid! PayCard account. The direct deposit(s) will be made on each payday, unless I notify YOUR COMPANY in writing of my intent to cancel. Upon YOUR COMPANY's receipt of a request to cancel a direct deposit authorization, it shall become effective after a reasonable opportunity to act upon it. In the event funds are deposited erroneously into my account, I authorize YOUR COMPANY to debit my account(s) not to exceed the original amount of the credit. I understand that YOUR COMPANY reserves the right to refuse any direct deposit request. I also understand that all direct deposits are made through the Automated Clearing House (ACH), and that funds availability is subject to the terms and limitations of the ACH as well as my financial institution. Note: If sending this form electronically, please type your initials and the last 4 digits of your social security number in the signature field. If sending or faxing a paper copy, please print out and sign your name(s) in the signature box.

Employee Signature*

Date*

Date