Automatic Payment Request Form Page 3
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6Automatic Payment Request Form
Name: _________________________________ Customer Account #: ____________________
I have a new account number and ask that you make a note of it for my next automatic payment
withdrawal.
I authorize ____________________________ to make automatic withdrawals, as per original
agreement, from the following Credit Union account number.
Routing Number: 324172575
Savings Account: __ __ __ __ __ __ __
Checking Account: __ __ __ __ __ __ __
Member’s Signature: ____________________________________ Date: __________________
**Verify with company if a voided check is needed.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Direct Deposit Form
Employee Name: ______________________________ Social Security No.: _______________
I authorize _____________________________________ to automatically deposit my payroll
each pay period to my CapEd account.
Routing Number: 324172575
Savings Account: __ __ __ __ __ __ __
Checking Account: __ __ __ __ __ __ __
Employee Signature: ____________________________________ Date: __________________
***This form is intended to be an easy way to remember the account numbers you will need to
start direct deposit. Your payroll department may have other forms for you to fill out. If a voided
check is needed to assist with the direct deposit to your checking, please have a MSR supply
you with one.
CapEd · P.O. Box 570 · 275 S Stratford Dr · Meridian, ID 83680 · (208) 884-0150 ·
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