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Wisely Pay Card Form 2

The document is a wage payment election and consent form for an employee to choose direct deposit of wages to an ADP Wisely Pay card and consent to the terms. The employee provides their information and elects to receive 100% of their net pay deposited to the Wisely Pay card each pay period. They acknowledge reading and agreeing to the cardholder agreement and fee schedule. The form also includes information required by law to help fight terrorism and money laundering when opening a prepaid card account.

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Lesly Rodriguez
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339 views2 pages

Wisely Pay Card Form 2

The document is a wage payment election and consent form for an employee to choose direct deposit of wages to an ADP Wisely Pay card and consent to the terms. The employee provides their information and elects to receive 100% of their net pay deposited to the Wisely Pay card each pay period. They acknowledge reading and agreeing to the cardholder agreement and fee schedule. The form also includes information required by law to help fight terrorism and money laundering when opening a prepaid card account.

Uploaded by

Lesly Rodriguez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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WAGE PAYMENT ELECTION AND CONSENT FORM

EMPLOYEE INFORMATION (print and complete all fields)

First Name Middle Initial Last Name


Victoria E Vargas Perez
Date of Birth (mm/dd/yyyy) Social Security Number Employee ID
08 / 03 / 1994 627 – 44 – 9627 800516317

Legal Address (No PO Box) Apt # (if applicable)


15700 e alameda parkway 304

City State Zip Code


Aurora CO 80017
Home Phone Mobile Phone Email Address
( ) – (720) 461–4884 [email protected]
Mailing Address (optional) Apt # (if applicable)

City State Zip Code

Home Phone Mobile Phone Email Address


( ) – ( ) –
WAGE PAYMENT ELECTION

✘ Wisely Pay by ADP card (indicate amount of deposit)

✘ Full Deposit: I want to receive 100% of my full net pay on my Wisely Pay card every payday

I confirm my authorization to be paid through the Wisely Pay by ADP card is fully voluntary. I acknowledge I have
received and read the Wisely Pay card Fee Schedule, Cardholder Agreement, and Privacy Notice. I understand that in
order to use the Wisely Pay card, I will need to accept and agree to the Cardholder Agreement and to pay the fees as
indicated on the Fee Schedule by activating my Wisely Pay card. By electing Wisely Pay card as my wage payment
choice, I am consenting to provide my personal information to ADP to enroll in and request a Wisely Pay card.
IMPORTANT INFORMATION ABOUT APPLYING FOR A NEW PREPAID CARD ACCOUNT - To help the government
fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify,
and record information that identifies each person who opens an account. What this means for you: When you open a
Prepaid Card account, ADP may require your name, address, date of birth, Social Security number, tax identification
number and other information that will allow ADP to identify you. ADP may also ask to see your driver's license or other
identifying documents. You will not be subject to a credit check.
CONSENT TO DEPOSIT WAGES
I authorize my employer (or its payroll service provider) to initiate credit entries each pay date to deposit my pay (either
net or a portion thereof) into the Wisely Pay card account selected in this election and consent (the “Account”). If funds to
which I am not entitled are deposited to my Account, I authorize my employer (or its payroll service provider), to initiate
any action to reverse or correct an erroneous credit entry to my Account and to direct the bank to return said funds to my
employer (either directly or through its payroll service provider), to the extent permitted by applicable law. I will review my
pay statement to ensure that my wages are being deposited correctly into my Account each payroll period. I understand
that I can change my election at any time by contacting my employer and that this authorization replaces any previous
authorizations and will remain in full force and effect until my employer (or its payroll service provider) has received written
notification from me of its termination and my employer (or its payroll service provider) and the bank has had a reasonable
opportunity to act on said termination.

Employee Signature Date


Victoria Esmeralda Vargas Perez 09/25/2023

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