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PaychekPLUS Elite Visa Payroll Card Enrollment Form Sign up today Complete the form below and return it to your employer. Inc. Consent to Payroll Card Account By signing below I authorize my wages and/or salary to be electronically deposited to my PaychekPLUS Elite Visa Payroll Card. Name Social Security Number Physical Address No PO Boxes City/State/Zip Mailing Address If different from physical address Date of Birth Phone Number Email Address For Manager Use Enter 10-digit Card ID The PaychekPLUS Elite Visa Payroll Card is issued by Comerica Bank pursuant to a license from Visa U.S.A. This authorization will remain in effect until my employer receives written notice from me terminating my consent and my employer has a reasonable opportunity to act on that notice. By providing a telephone number I expressly consent to receiving calls regarding my card account at this number including auto-dialed calls and prerecorded or artificial voice message calls. Calls to a mobile number may incur fees from my cellular provider. I understand that my Payroll Card Account and associated direct deposit account number cannot be used for preauthorized direct debits from merchants or from utility or Internet service providers. If presented for payment these preauthorized direct debits will be declined and my payment to the merchant or provider will not be processed* The bank routing number and direct deposit account number are for the purpose of initiating direct deposits to my Payroll Card Account only. I am not authorized to provide this bank routing number and direct deposit account number to anyone other than my employer or other payer. funds will start. Funds availability is subject to timing of payer s funding. Important Information about Procedures for Creating a Payroll Card Account To help the government fight the funding of terrorism and money laundering activities federal law requires all financial institutions to obtain verify and record information that identifies each person who opens an account. What this means for me When I apply for a Payroll Card I will be asked for my name address date of birth and other information that will allow you to reasonably identify me. I may also be asked to see my driver s license or other identifying documents at any time. Employee Signature Date. This authorization will remain in effect until my employer receives written notice from me terminating my consent and my employer has a reasonable opportunity to act on that notice. By providing a telephone number I expressly consent to receiving calls regarding my card account at this number including auto-dialed calls and prerecorded or artificial voice message calls. By providing a telephone number I expressly consent to receiving calls regarding my card account at this number including auto-dialed calls and prerecorded or artificial voice message calls. Calls to a mobile number may incur fees from my cellular provider. I understand that my Payroll Card Account and associated direct deposit account number cannot be used for preauthorized direct debits from merchants or from utility or Internet service providers.

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