Regions Now Card Direct Deposit Form WHY SIGN UP FOR REGIONS NOW CARD DIRECT DEPOSIT? It’s a Bargain. Pay no monthly fee with qualifying direct deposits of $500 or more per month. It’s Convenient. Your check is automatically loaded onto your reloadable prepaid Visa® card. It’s Safe. You’ll never have to worry about a check getting lost, delayed or stolen. GET STARTED TODAY. SETTING UP DIRECT DEPOSIT IS EASY. • If your payor is a government agency listed in the table below, your payor may require you to submit a separate form in order to complete your direct deposit request. Simply use the information below to contact your payor and request information about how to enroll in direct deposit. • For all other employers or payors, complete and sign the form below and give it to your employer or payor. Please begin making payments by direct deposit to my Regions Now Card.SM ____________________________________________ Name (please print) ___________________________ Date ________________________________________________________________________________ Address City State ZIP ________________________________________________________________________________ Phone 065402892 Regions Now Card Routing Number Direct Deposit: 100% of my pay ____________________________________________ Account Number – Your 16-digit Regions Now Card Number Other Amount $_______________ or ______________% Ability to specify amount or percentage of pay to be direct deposited may not be available for some employers. ________________________________________________________________________________ Signature U.S. GOVERNMENT PAYOR Social Security • Supplemental Security Income Veterans Compensation and Pension CONTACT INFORMATION 1.800.772.1213 • socialsecurity.gov 1.877.838.2778 • va.gov © 2011 Regions Bank. You can cancel this direct deposit authorization at any time. To cancel, you must give written notice to both your payor and Regions Bank. Your cancellation will become effective when your payor receives your notice of cancellation and has had a reasonable period of time on which to act on it. Any direct deposit of funds to your Regions Now Card by your payor up until that time will be authorized by this authorization form. All direct deposit of funds under this authorization will be subject to all rules, regulations and agreements and disclosure statements of the payor and Regions Bank governing the Regions Now Card and funds loaded onto the Regions Now Card.