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Direct Deposit Authorization Form
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BY USING THIS CARD YOU AGREE WITH THE TERMS AND CONDITIONS OF THE CARDHOLDER AGREEMENT AND FEE SCHEDULE, IF ANY
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Full Name:Date:
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Authorization Agreement
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I authorize my Employer / Payor to initiate credit entries for the direct deposit of my
entire pay check or other amount to my prepaid card on a recurring basis,
including, if necessary, to initiate any debit entries and adjustments to correct any
erroneous credit entries.
This authorization will remain in efect until I revoke (cancel) it in writing
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Account Authorization
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Account Holder
Signature:
Date:
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Indicate the amount you want deposited per pay period
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Entire Check
Amount
% of check$per check
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(50% for example)(fixed dollar amount, such as $350)
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John Doe
123 Example St
Las Vegas, NV 89116
Date:
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PAY TO THE ORDER OF$1.00
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One Dollar
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Metropolitan Commercial Bank 99 Park Ave. | 4th Floor New York, NY 10016
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MEMO
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Routing Number
Account Number
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