Payroll Allocation

Mail this form to:

From:

VSECU

One Bailey Avenue

PO Box 67

Montpelier, VT 05601

Re:

Employer Name:

Dear Member Service Consultant:

Please allow this to serve as my formal request to allocations to the account(s) listed below.

Account #	Checking	Savings	Loan	Other	Amount
Account #	Checking	Savings	Loan	Other	Amount
Account #	Checking	Savings	Loan	Other	Amount
Account #	Checking	Savings	Loan	Other	Amount
Account #	Checking	Savings	Loan	Other	Amount

In the event the funds received exceed the amount allocated, provide the account number you would like the additional funds allocated to below. In the absence of a selection your Share Savings account will receive the funds.

Residual Account Checking Savings Other

Please note if you are changing your allocation, you must provide a complete allocation for all funds and all accounts. Only the allocation specified above will be put into effect.
Changes may take up to two pay periods to take effect. Please plan accordingly.

If you worked with a Member Service Consultant, please enter his/her name here:

_______________________________________

Primary Account Holder Signature/Date

By signing, I approve the above distribution of my payroll deduction and/or ACH credits.

Phone #(s):

Day:

Evening:

Mobile: