Employee Pay Selection Record (PSR)
We offer three options to receive your pay, Direct Deposit, the Money Network® Service, or a paycheck. Please review
these options and make your selection below.
Option 1: DIRECT DEPOSIT
If you want all of your net pay deposited into your account at your financial institution (Account), provide your routing and
account numbers and account type (collectively, Account Information) in accordance with our direct deposit procedure.
We cannot require you to select direct deposit and doing so is not a condition of your employment.
Option 2: MONEY NETWORK SERVICE
PLEASE REVIEW THE MONEY NETWORK SERVICE PREPAID DISCLOSURES PROVIDED WITH THIS PSR.
If you want us to pay all of your net pay using the Money Network Service, choose this option to receive the Money Network
Welcome Packet. The Money Network Welcome Packet contains the Terms and Conditions that apply to the Money
Network Service, the fee schedule for the Money Network Service, and other important disclosures about the Money
Network Service. When you are enrolled into the Money Network Service, you may use the Money Network Service after
you consent to the Terms and Conditions by activating your Money Network Service account and following the instructions
in the Welcome Packet. If you work in New York, we must wait 7 business days after you complete this PSR before we
can give you a Welcome Packet or enroll you in the Money Network Service. You can access your pay in full for free1 at
any time by using a Money Network® Check (Check) or the optional Money Network Debit Card (Card). You can complete
the Check and deposit it into your personal bank account, cash the Check for free1 at Money Network check-cashing
partners, or use the Check for any other purpose. If you work in New York, you will not be charged declined transaction
fees at an ATM that does not provide free balance inquires. You can access a list of the closest free1 ATM locations or
Money Network check-cashing partners to your residence or place of employment by using the Money Network Mobile
App* or [Link]. Third party check cashing services may charge you a fee to cash the Check. We cannot
require you to select the Money Network Service and doing so is not a condition of your employment.
Option 3: PAYCHECK.
If you want us to pay all of your net pay with a paycheck, choose this option and we will make a paycheck available to
you.
I ELECT TO HAVE MY PAY DISTRIBUTED AS INDICATED:
(REQUIRED: MAKE ONE CHOICE BY WRITING YOUR INITIALS IN THE BOX FOR OPTION 1, 2, OR 3 SHOWN
BELOW.)
Option 1 Option 2 Option 3
Initials: Initials: Initials:
OR OR
MONEY NETWORK
DIRECT DEPOSIT PAYCHECK
SERVICE
I give you my consent to pay me by direct deposit, the Money Network Service, or paycheck, according to the selection I
checked and initialed above. If I do not select direct deposit or the Money Network Service, I will be paid by a
paycheck. I understand that I can change my wage payment selection at any time by submitting a new PSR. If I select
to be paid by direct deposit or the Money Network Service and am paid funds to which I am not entitled, I authorize you to
withdraw such funds from the Account or the Money Network Service, as applicable. I may view and print this PSR at work
without any cost to me. If I select the Money Network Service, Money Network will open an account for me at the bank that
issues my Card and Money Network Checks. Federal law requires Money Network to verify and record my identity
information before opening my account. To meet these requirements, I authorize you to share my Form I-9 information,
including my name, address, date of birth, Social Security Number, identification documents, and related personal
information with Money Network and the issuing bank.
EMPLOYER USE ONLY
Signature Printed Name Date Employee ID Number
* Standard message and data rates apply.
1 While this specific feature is available for free, certain other transaction fees and costs, terms, and conditions are associated with the use of this Card. See the fee
schedule for the Money Network Service for more details.
PSR M-3 MN PSR - DD + MN + EIC (including NY + NH) - Standard – ver. 23JUL20