ExxonMobil Credit Union Direct Deposit Election Authorization
Date: Social Security Number Name of Employee
Credit Union Routing #

265075304 		Credit Union Account #

Credit Union Name:

Coastland Federal Credit Union
Credit Union Contact Phone Number

Please check only one box

New election

Change prior election

Cancel election

 Account Type

Checking

Savings 		Amount of Credit Union Election

$_________Per Pay Period|

(This should be the total amount you want sent
to the Credit Union for all loans, savings, etc.)

I authorize the above amount to be sent to my Credit Union account every pay period.
Signature of Employee:

_______________________________________________________________________
This agreement authorizes Payroll Services to deposit payments via electronic funds transfer
into the account shown and to initiate adjustments for any entries made in error to the account.
This authority is to remain in effect until Payroll Services has received written notification from
the Credit Union of its termination or change in such time and in such manner as to afford
Payroll Services a reasonable opportunity to act on it. A cancellation authorizes future
payments to be distributed according to your payroll distribution election.

PLEASE MAIL COMPLETED FORMS TO:

Coastland Federal Credit Union
2644 N. Causeway Blvd.
Metairie, LA 70002

Fax: (504) 834-2069

Forms received after the 18 th of the month will not be processed until the next month. Changes would then not be effective until the following month.