*CONFIDENTIAL - Contains Personally Identifiable Information* PAYROLL DEDUCTION AUTHORIZATION FOR U.S. SAVINGS BONDS
Authorization Type: Circle type below and complete sections identified by (number) (1-5) New (1 & 5) Change Beneficiary (1) Cancel (1 & 4) Change Address (1 & 3) Change Owner (1 & 2) Change Deduction (1 & 5) Change Co-Owner (1 & 2) Change Maturity
(1)
PSR ______ Hourly _____ : Badge or Area Code______________ Pay Loc. No. ____________________ Social Security No. __ __ __ - __ __ - __ __ __ __ Employee Name: ______________________ (Given First Name) ________ M. I. __________________________ (Last Name) Salary ______
(2)
I authorize my employer to deduct from each pay the sum of $___________ (must be in multiples of $ .25) for the purchase of Series "EE" Savings Bonds in the maturity value of $ ___________.
Cost
Maturity
______ $ 50.00 100.00 250.00 500.00
_________ $ 100.00 200.00 500.00 1,000.00
(3)
Bond Owner: Must complete A or B, but NOT BOTH ________________________ Given First Name (B) Bond Owner Name (When other than employee) __ __ __ - __ __ - __ __ __ __ Soc. Sec. Number (Required) (A) Employee Name: ______ M. I. ____________________ Last Name
______________________ _____ _________________ Given First Name M.I. Last Name
(4)
Address to which bonds are to be mailed: (Complete all information in this section) _____________ Number _______________________ Street ______________________ ______ __________ City State Zip Code
(5)
Co-Owner or Beneficiary: (Check one) Co – Owner ______ Beneficiary _________ None __________ Name only one person: ______________________ _____ ______________________ Given First Name M.I. Last Name
This authorization will continue in effect until changed or cancelled by me in writing or termination of my employment. This authorization automatically cancels any prior authorization and any deducted but unexpended amount shall be applied to purchase bonds under this authorization. It is understood that no interest is to be paid by my employer on any accumulated deductions. In the event of my death, my employer will pay to the designated owner, co-owner or beneficiary indicated above the unexpended amount of accumulated deductions to my credit. In the event this authorization is cancelled by me or by termination of employment, my employer will pay to me the unexpended amount of accumulated deductions to my credit. I have read and agree to the conditions covering the Payroll Savings Plans as explained above. PLEASE CHECK THIS AUTHORIZATION FOR LEGIBILITY AND ACCURACY BEFORE SIGNING.
Note: No Trusts No Estates
Employee Signature ___________________________ Bldg. Name ___________________ Phone No. _________________ Date _______________________