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WAGE PAYMENT ELECTION AND CONSENT FORM page 1 of 2

EMPLOYEE INFORMATION (print and complete all fields)

First Name Middle Initial Last Name

Date of Birth (mm/dd/yyyy) Social Security Number Employee ID

___ ___ / ___ ___ / ___ ___ ___ __ ___ ___ ___ – ___ ___ – ___ ___ ___ ___
Residential Address (PO Box is not allowed if electing ALINE Card as wage payment method) Apt #
(if applicable)
City State Zip Code

Home Phone Mobile Phone

( ) – ( ) –

WAGE PAYMENT ELECTION

PLEASE SELECT ONE OF THE THREE OPTIONS PROVIDED BELOW:

☐ Direct Deposit (indicate amount of deposit to each account type and provide account number )
VOIDED CHECK or BANK LETTER MUST BE ATTACHED
ATTACH CHECK/LETTER HERE

I 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 to my checking and/or savings account each pay period. I
acknowledge that the orignination of ACH transactions to my account must comply with the provisions of U.S. Law.
This authority will remain in effect until I 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 ☐ Savings ☐ Checking ☐ Savings ☐ Checking ☐ Savings

Bank Bank Bank

Routing # Routing # Routing #

Account # Account # Account #

☐ 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.]
I confirm my authorization to be paid through the WISELY Card is fully voluntary. I understand that in order to use the
WISELY Card, I 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 Card. By electing WISELY Card as my wage payment choice, I 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 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
to a credit check.

☐ WISELY Check – I understand that although I will be enrolled in the WISELY Pay Program, I 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.
 page 2 of 2

MUST ENTER ACCOUNT NUMBER FOR ADP WISELY PROGRAM (WISELY CARD or WISELY
CHECK)
Enter Account number from the ADP Wisely Packet envelope window

ACCOUNT NUMBER: _____________________________

CONSENT TO DEPOSIT WAGES

I authorize my employer (or its payroll service provider) to initiate credit entries each pay date to deposit my pay (either net
or a portion thereof) into the checking, savings or Wisely Card account selected in this election and consent (the “Account”).
If funds to which I am not entitled are deposited to my Account, I authorize my employer (or its payroll service provider), to
initiate any action to reverse or correct an erroneous credit entry to my Account and to direct the bank to return said funds
to my employer (either directly or through its payroll service provider), to the extent permitted by applicable law. I will review
my pay statement to ensure that my wages are being deposited correctly into my Account each payroll period. I understand
that I can change my election at any time by contacting my employer and that this authorization replaces any previous
authorizations and will remain in full force and effect until my employer (or its payroll service provider) has received written
notification from me of its termination and my employer (or its payroll service provider) and the bank has had a reasonable
opportunity to act on said termination.

CONSENT TO ELECTRONIC PAY STATEMENTS

I agree to receive and access all of my pay statements on or before each regular pay day electronically on the ADP
Website, a secure website, rather than receiving a paper statement, until I withdraw my consent. I understand that I may
retain a copy of the pay statement by saving it to my computer or by printing a hard copy of it. I understand that I should
not save my statement to a public computer as others may see my statement. (Note: Your statements will remain on the
secure website for 3 years. If you want to retain a copy for a longer period, you must either print a copy or save an
electronic copy.)

I understand that I may withdraw this authorization at any time. I acknowledge that the mere request for a paper pay
statement will not be considered withdrawal of my consent. I understand this consent applies to pay statements furnished
every pay period until my consent is withdrawn. (Note: The withdrawal of your consent will not be effective and you will not
start receiving paper statements for 1 or 2 additional payroll cycles.)

Employee Signature Date

Return this completed application form via fax to (205) 912-7318, or mail to:

Attn: PAYROLL DEPARTMENT

2700 Milan Court
Birmingham, Alabama 35211