Direct deposit enrollment form

Sign and deliver this form to your employer or payroll provider, and we’ll take care of the rest.

VOID
Voided check

0000
PAY TO THE

ORDER OF $
DOLLARS

ROUTING NUMBER BANK NAME

073972181 Pathward

Authorization
Direct Deposit via ACH is the deposit of your payroll, government benefits, tax and other
refunds, annuities, and interest payments to your Coinbase Account.

I authorize (employer / payer) to electronically deposit my

paycheck to my Coinbase Account (account number1) and, if
necessary, debit entries and adjustments for any errors to my account each pay period2. This
authority will remain in effect until I notify my employer or payer in writing or as otherwise
specified by my employer.

Choose deposit amount (per pay period)

Deposit my entire paycheck Deposit $ dollars Deposit %
of my paycheck of my paycheck

YOUR NAME

YOUR SIGNATURE DATE