Mercedes-Benz USA, LLC
AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYROLL AND ACCOUNTS PAYABLE DEPOSIT
To: Payroll Department, Montvale Check One: [ ] New Authorization [] Cancellation

[ ] Change – Please note reason: ____________________________________________ Please Print Financial Institution: ________________________________________________________________

Address (Local Branch): ________________________________________________________________ City, State, Zip Code: ________________________________________________________________

Transit Routing (ABA) # ________________________________________________________________ (available from your bank must be 9 positions) Checking or Savings: ________________________________________________________________

Account Number: ________________________________________________________________ (No more than 17 positions) Please attach a blank voided check. It must show the bank imprinted account and transit routing numbers. If this information is not attached your request will not be processed. Please Print Employee Name: ________________________________________________________________

Cost Center and Phone #: ________________________________________________________________ Employee ID Number: ________________________________________________________________

Employee Email Address: ________________________________________________________________

I authorize Mercedes Benz USA, LLC to make payroll deposits to my account as indicated on the attached blank voided check. I understand these deposits will be made on paydays only; this does not include weekends or federal holidays. I understand it is my responsibility to verify the availability of funds prior to drawing against them. In the event of an overpayment on my paycheck, I authorize Payroll to withhold a sum equal to the overpayment from my next paycheck or debit identified checking account of the amount of the incorrect check. This is subject to all applicable federal/state law. I am responsible for notifying Payroll of any changes to my account number or financial institution. This authorization will remain in full force until MBUSA, LLC. has received written notification from me of its termination, in such time and such manner as to afford MBUSA, LLC. and the financial institution named above a reasonable time period to process the request.

Signature:

___________________________________________

Date: _______________