24 12.20 HIBBETT | CITY GEAR WAGE PAYMENT ELECTION AND CONSENT FORM page 1 of 2 EMPLOYEE INFORMATION (print and complete all fits) FirstName : T Midas tatlal Last Name ac AnNPetw DOHERTY Date of Birth (mmidalyyyy) Social Securly Number Employes 1D Seeger ee egg Residential Address (PO Box is not allowed if electing ALINE Card as wage payment method) Apt# 2725 Cle. Axcurie ae i: (if applicable) oy Site Zip Code Biewmiag hes i Ae. 3¢ Home Phone | Mobile Phone iene fot: WAGE PAYMENT ELECTION PLEASE SELECT ONE OF THE THREE OPTIONS PROVIDED BELOW: 1 Direct Deposit (indicate emount of deposit to each account type and provide account number) /OIDED CHECK or BANK LETTER MUST BE ATTACHED | authorize Hibbett Sporting Goods Inc / City Gear, LLC to initiate electronic credit entries, and if necessary, debit ~ eeiries and adjustments for any credit entries in error to my checking and/or savings account each pay period, | acknowledge that the orignination of ACH transactions to my acoount must comply with the provisions of U.S. Law. This authority will remain in effect until | have sent a request of cancellation in Writing to the Payroll Department of ibbett Sporting Goods / City Gear. Direct Depositi#t § Direct Deposit#2 § Direct Deposit #3 $ Checking Ci Savings OChecking =O Savings * Checking 11 Savings. Bank Bank Bank is sy 99 Routng# OSD IIESTT routings ~ Routing # es 3Y3H Y3LL91/N93H9 HOVLLY Account# _G A? [772 Account Account # Cl 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 Fes ‘Schedule by activating my WISELY Card. 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 taw 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 toa credit check. CO WISELY Check ~ | understand that although | will be enrolled in the WISELY Pay Program, | am not required to activate or use an WISELY Card to use the WISELY Check to receive my full net pay. WISELY Check will be the default payment method if no other wage payment method is selected.