League Central Credit Union Payroll Deduction Form Page

Payroll Deduction Form

To send form electronically to our e-mail, complete the form on screen and click
"Submit Form Electronically" at the bottom of the page. If submitted electronically, you will receive a confirmation email letting you know we received the request. Press Submit Once an Error will occur if the form failes. Thanks.

Or, because e-mail is not always a secure method of sending information, you may choose to complete the form on screen and click "Print Form" then fax, mail, or bring by the Credit Union.

Member Information:

First Name:

Middle Initial:

Last Name:

Last 4 digits of Account Number:

Employer:

E-Mail Address:

Mailing Address:

City:

State:

Zip:

Date of Birth:

Mother's Maiden Name:

Home Phone:

Work Phone:

Total Amount to be Deducted
(if entire paycheck, put NET):

This is to authorize my employer to deduct from my salary the sum designated above each pay period and remit same to League Central Credit Union to apply on my share and loan balances.

Please distribute the above sum to the following accounts:

Savings:

Checking:

Christmas Club:

Insurance:

Roth IRA Accounts:

IRA Accounts:

IMMA:

Family Accounts*:

* Primary Account
Holder’s Name:

Other:

• I understand that participation in the Insurance Program is voluntary.
• I understand that premature cancellation of the Insurance Program could result in
full or partial forfeiture of premiums as specified in the policy.
• I understand that in all cases, if a loan payment is agreed to, it will be deducted
from my Savings Account first. I also understand that my account cannot be
closed until all payroll deductions have been credited and verified by the credit union.
• I understand that should I elect to close this account within six months of opening,
I will be accessed a $15.00 processing fee.

Electronic Signature:

Date:

Please contact your company's payroll department and make them aware
of the changes you have made to your account.