Name:______________________________________ Address:_____________________________________________

City:_______________________________ State:___________________________ Zip Code:_____________________

This authorization will remain in effect until it is cancelled in writing. Your wage statement will be made available to you by your employer or government benefits office.

I hereby authorize (employer or originator name)_________________________________________

Address: _______________________________________________ City_____________________

State: ______________________ Zip Code:_____________ Phone No.:______________________

to deposit wage payments, expense reimbursements, or other compensation directly to my Stored Value Card Account.

My full 11-12 digit Prepaid MasterCard Card direct deposit account number is:

5110 71_ _ _ _ _ _

If you do not know your 5-6 digit card account direct deposit number, contact cardholder services at 1-800-906-6126 or access your card account online at www.myheritagemc.com. THIS IS NOT THE NUMBER ON THE FRONT OF YOUR CARD.

By signing below, you state that the information given on this form is true to the best of your knowledge, and that you’ve read and understand the information on this enrollment form.

Employee Signature ___________________________________________ Date Signed ___________________________

(Employer: Please Retain a Copy of This Form for Your Records)

How to Direct Deposit to Your Stored Value Card

Listed below are instructions that you will need to set up direct deposit onto your stored value card:

1. Complete the information requested on the top of this form. Remember to sign your form to ensure FDIC coverage.

2. Be sure the information listed below is put on the direct deposit form that you fill out. For the Bank Name, list Palm Desert National Bank as it appears below. For the routing number, list it exactly as it appears below. When asked for your direct deposit account number, it is 511071 + the 5-6 digit account number that has been assigned to your prepaid MasterCard Card. When choosing the account type, list CHECKING.

Bank Name / City / State Palm Desert National Bank, Palm Desert, CA

Routing / Transit Number 122238585

Account Number 511071________________________(fill in your 5-6 digit card account number)

Account Type CHECKING

Upon completing this direct deposit form, return it to your employer or the form originator. You may also be required to complete and sign a direct deposit authorization form from your employer or the originator of your direct deposit. Keep a copy for your records.