504 Clubview Drive
Levelland, TX 79336-6312

Fax Number: 806-897-4071
Employee Payroll Deduction Authorization
Home Phome    
Member No:
 Work Phone
Initial Authorization
Change in Authorization
I hereby authorize my employer to deduct from my salary the amounts set forth in this Authorization and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. I understand that this Authorization is revocable. If this a change in a previous Authorization, I instruct my employer to cancel my previous Authorization and to follow this Authorization. If I fail to cancel this Authorization upon filing for bankruptcy, my employer and the Credit Union are directed to make and apply deductions in accordance with this Authorization. I grant the Credit Union a power of attorney to increase or decrease the amount of my deduction upon my written or verbal request. This power of attorney only applies to a loan or credit extension for which the payment may vary. I authorize my employer to honor any payment change made under this power of attorney.

Payroll Deduction Amount:   $_____________________

Payroll Period:

Weekly Biweekly    Monthly      Semi-Monthly


Effective Date
Effective with this form, my payroll deduction will be distributed as follows (must include all distributions)
1. Regular Savings: $_____________________
2. Vacation Club:   $_____________________
3. Christmas Club: $_____________________
4. Loan Payments:  $_____________________
5. Loan Payments: $_____________________
6. Loan Payments: $_____________________
7. Other: ______________________ $_____________________
8. Other: ______________________ $_____________________
9. Other: ______________________ $_____________________
Total Deduction Per Paycheck
Add lines 1 - 9 from above for total
You Must Print, Sign, and Return to HCSECU
(by mail, fax or in person)
A signature is needed to complete the process