Direct Deposit Enrollment Form

Account Type Checking Saving

Bank Routing Number____________________________________________________________

Account Number*___________________________________________________________

Attach Voided Check Deposit Slip

I hereby authorize KCHA to initiate deposits (credits) and/or (debits) corrections to the above stated bank account as indicated. The financial institution is authorized to credit and/or debit the amounts to my account. KCHA has 5 days to make corrections after initial deposit. This authority remains in force until KCHA receives written notification from me of its termination.

Authorized Signature________________________________ Date__________________

600 ANDOVER PARK WEST SEATTLE, WASHINGTON 98188-2583

PHONE (206) 574-1100 FAX (206) 574-1104

EQUAL HOUSING OPPORTUNITY