Changes to your direct deposit should be submitted to the HR Department by completing the Direct Deposit Change Form.

The change will be effective on the pay period following receipt of the Direct Deposit Change Form. You can use this sheet as a fax cover sheet.

To: Fax:

HR Department (800) 783-5540

Employee Name:

younan oraha __________________________

Employee EID:

801512 ___________________________ 773-988-3791 ___________________________

(In case we have questions regarding your form)

Phone:

Direct Deposit/Pay Card Enrollment Change Form

In an effort to be green, IMPACT Resource Group requires all employees to receive their pay through direct deposit or a pay card. Your pay can be deposited in up to three different accounts. This can include any combination of checking accounts, savings accounts or deposits onto a Chase Pay Card. ACCOUNT/PAYCARD TO CANCEL Check all that apply: Cancel all future deposits onto my Chase Pay Card. Name on Pay Card: Cancel my pay by direct deposit. ACH Routing # (9 digits): Account #:

ADD PAYCARD I want to receive my pay by Chase Pay Card. Please send me the information to activate my pay card. Name on Pay Card: Amount to be deposited (dollar amount): I want to receive my pay by Chase Pay Card. Please send me the information to activate my pay card. Name on Pay Card: Amount to be deposited (dollar amount): ADD DIRECT DEPOSIT ACCOUNT I want to receive my pay by direct deposit. Attach a voided check, copy of a check, or spec sheet for the account. Indicate whether it is a checking or savings account. (No deposit slips) Checking or Savings Account? Bank Name: Amount to be deposited (dollar amount):

checking TCF all checke

Account #: ACH Routing # (9 digits):

8877064012 271972572

I want to receive my pay by direct deposit. Attach a voided check, copy of a check, or spec sheet for the account. Indicate whether it is a checking or savings account. (No deposit slips) Checking or Savings Account? Bank Name: Amount to be deposited (dollar amount): By signing below, I hereby authorize and request IMPACT Resource Group to make deposits in the account(s) identified above and authorize the bank to accept such deposits. Account #: ACH Routing # (9 digits):

younan oraha Employee Name: _________________________________________________ 5510 n . luna .ave Address: __________________________________________
Employee Signature: ______________________________________________

801512 Employee ID: _________________________

State:______ IL

City: ______________________ chicago

60630 Zip:_______

Date: ________________________________ 6/28/2012