A246 1220 HIBBETT | CITY GEAR WAGE PAYMENT ELECTION AND CONSENT FORM page 1 of 2 EMPLOYEE INFORMATION (print and complete all fields) First Name Widale tniiat | Last Name ee ANDrEw DoHO2Ty Date of Birth (mmiddiyyyy) ] Social Security Number Employee ID GRE een eee acne ae eee are eae eee ae Residential Address (PO Box sno alowed if elocing ALIME Cords wage payment method) | ADL 27265 de. Avene (applicable) City State Zip Code .. _ Racing brs AL 352.22 Home Phone Mobile Phone £ ) = it ) vm WAGE PAYMENT ELECTION. PLEASE SELECT ONE OF THE THREE OPTIONS PROVIDED BELOW: 1 Direct Deposit indicate amount of deposit to each account type and provide eccount number) VOIDED CHECK or BANK LETTER MUST BE ATTACHED 3Y3H Y3L191/493HI HOVLLY | authorize Hibbett Sporting Goods Inc / City Gear, LLC to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error fo my checking andlor savings account each pay period. | acknowledge that the orignination of ACH transactions to my account must comply with the provisions of U.S. Law. This authority will eemain in effect until | have sent a request of cancellation in Writing to the Payroll Department of Hibbett Sporting Goods / City Gear. Direct Deposit #1 $ Direct Deposit#2 — $ Direct Deposit #3 $ Checking Cl Savings (Checking Savings > (Checking 1 Savings Bank a ee, Bank Bank Routingt# OS IACSIY Routing # Routing # Account# GS? 172 Account # Account # Ci WISELY Card (NOTE: If you do not indicate WISELY Card as your wage payment election and you later activate the WISELY Card without signing a new election form, by activating the WISELY Card, you are confirming your election and consent as stated below.] | confirm my authorization to be paid through the WISELY Card is fully voluntary. | understand that in order to use the WISELY Card, | 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 Gard. By electing WISELY Card as my wage payment choice, | am consenting to provide my personal information to ADP to enroll in and request an WISELY 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 requites all financial institutions to obtain, verily, and record information that identifies zach person who opens an account, What this means for you: When you open a Prepaid Card account, ADP may requite your name, address, date of birth, Social Security number, tax identification number and other information that wll allow ADP to identify you. ADP may also ask to see your drivers license or other identifying documents. You will not be subject to @ credit check. (3 WISELY Check ~ | understand that although I willbe enrolled in the WISELY Pay Program, | am not required to activate oF use an WISELY Card to use the WISELY Check to receive my full net pay. WISELY Check will be the default ‘smanvened radians! Orevetiien mame mmereiavedinal temsleeied