STATE EMPLOYEES CREDIT UNION RETIREE PAYROLL DEDUCTION AUTHORIZATION
Instructions 1) Complete the information requested below. Type or print clearly in ink. 2) Mail or fax this form to the SECU at the address below: State Employees Credit Union FAX (404) 651-8632 Attention: Member Services Dept. 400 Whitehall Street SW Atlanta GA 30303-3720 3) SECU will process this form and forward the deduction amount to the Employees' Retirement System of Georgia for this to be set up as a deduction from your retirement payment. th 4) If this form is not received by SECU by the 15 of the current month, it may not be reflected as a deduction from your retirement payment until the following month. 5) If you are not currently a member of SECU, you must also complete the SECU Membership Application, available at www.secuga.org or you can contact SECU at 404-656-3748 to have an application mailed to you. Please submit this form concurrently with the Membership Application.
First Name Middle Initial Last Name
Your Social Security Number
Your Home Mailing Address (Street/P.O. Box) Phone: Home Area Code – / Phone Number – /
(Apt.No.) City State Zip Code County / Extension (if any) Other Area Code – / Phone Number – / / Extension (if any)
I authorize the Employees' Retirement System of Georgia to begin deductions from my retirement check each month to be remitted to the State Employees Credit Union and credited to my accounts as follows: LOANS: ACCOUNTS: (A) CAR LOAN $__________________ (A) REGULAR SAVINGS $__________________ (B) DEPOSIT LOAN $__________________ (B) CHRISTMAS CLUB $__________________ (C) LINE OF CREDIT $__________________ (C) IRA $__________________ (D) HOME EQUITY $__________________ (D) OTHER $__________________ (E) OTHER $__________________ (E) CHECKING $__________________ $__________________ $__________________ LOAN TOTAL ACCOUNTS TOTAL GRAND TOTAL $
____________
Authorization & Acknowledgments. I understand this authorization for deductions replaces any previous authorization and will remain in effect until terminated by me in writing. I wish to continue making my loan payments by payroll deduction until such time as I decide to terminate deductions, even in the event of bankruptcy, and if I fail to so terminate, I request that payments continue to be made voluntarily to the loans in accordance with my pre-bankruptcy instructions.
Signature Date
Credit Union Use Only