PAYROLL DEDUCTION REQUEST
NAME                                                                                                        DATE
SOCIAL SECURITY NUMBER
ACCOUNT NUMBER
EMPLOYER
I AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY PAYCHECK AS
INDICATED AND TRANSMIT THIS SUM TO MID AMERICAN CREDIT UNION.
I AM PAID WEEKLY EVERY OTHER WEEK
  TWICE MONTHLY MONTHLY
CHECKING $________________________
LIFE INSURANCE SAVINGS $________________________
BASIC SAVINGS $________________________
CHRISTMAS SAVINGS $________________________
PAYROLL PLUS $________________________
LOAN#___________________ $________________________
LOAN#___________________ $________________________
OTHER___________________ $________________________
OTHER___________________ $________________________
OTHER___________________ $________________________

TOTAL DEDUCTION
EACH PAY PERIOD

 $________________________
 
SIGNATURE
X
ABA Routing #301180124

Mail completed form to:
Mid American Credit Union
8404 West Kellogg Drive
Wichita, Kansas 67209