MUNICIPAL CREDIT UNION DIRECT DEPOSIT DISTRIBUTION REQUEST

<table><thead><tr><th colspan="5">ACCOUNT NUMBER</th><th colspan="4">DEPOSIT ACCOUNT NUMBER</th></tr></thead><tbody><tr><td colspan="5">1580663</td><td colspan="4"></td></tr><tr><td colspan="5">NAME</td><td colspan="4">EMPLOYER ID</td></tr><tr><td colspan="5">MR CLYDE WASHINGTON</td><td colspan="4"></td></tr><tr><td colspan="5">SOCIAL SECURITY #</td><td colspan="4">PAYROLL GROUP</td></tr><tr><td colspan="5"></td><td colspan="4">000000</td></tr><tr><td colspan="5">TOTAL DEDUCTION</td><td colspan="4">TYPE ID</td></tr><tr><td colspan="5">$ 1,086.12</td><td colspan="4">SHARE 02</td></tr><tr><td colspan="3">WEEKLY</td><td colspan="3">BI-WEEKLY</td><td colspan="3">MONTHLY</td></tr><tr><td>ACCOUNT#</td><td>TYPE</td><td>ID</td><td>AMOUNT</td><td>ACCOUNT#</td><td colspan="2">TYPE</td><td>ID</td><td>AMOUNT</td></tr><tr><td></td><td>LOAN</td><td>21</td><td>$ 45.50</td><td></td><td colspan="2"></td><td></td><td>$</td></tr><tr><td></td><td></td><td></td><td>$

I authorize Municipal Credit Union to distribute the direct deposit of my payroll or US government payment as noted on this form. I understand that in order for the direct deposit of my paycheck or government payment to begin I must first complete and file a separate agreement with my employer or the appropriate government agency. If ever an incorrect amount should be deposited to my account(s). I authorize the Municipal Credit Union to make the appropriate adjustments. I also acknowledge receipt of the Electronic Funds Disclosure statement.

NOTE: Any portion of a direct deposit not specifically designated for distribution to a particular account will be deposited in to the account you designated on the direct deposit authorization form.



Signature:

Date



05/31/19



EFTA00124588