DIRECT DEPOSIT SIGN–UP AUTHORIZATION FORM I hereby authorize Matthew Plocher – Northwestern Mutual Los Angeles (hereinafter “Agency”) to deposit any amounts owed to me by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated below on this form. Further, I authorize the Bank to accept credit entries indicated by the Agency to my account. In the event of an erroneous entry made to my account, I authorize the Agency to make correction entries for amounts not to exceed the original erroneous amount. The Agency has agreed to notify me prior to making such adjustments. This authorization is to remain in full force and effect until the Agency and the Bank have received a written notice from me of its termination in such time and in such manner as to afford the Agency and the Bank reasonable opportunity to act on it. Please attach a Voided Check for the checking account listed below. BANK NAME ROUTING # ACCOUNT # AMOUNT Entire commission cycle balance ACCOUNT TYPE (Checking/Savings) _______________________________ Print Name ____________________________________ Social Security Number _______________________________ Signature ____________________________________ Date
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