Prepaid MasterCard® Card
Payroll Direct Deposit Enrollment Form
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. Whe