Bank Draft Authorization Form

Bank Draft Authorization

PARTICIPANT INFORMATION

Full Name(Required)

First Middle Last

Date of Birth(Required)

Account Number

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone Number(Required)

Phone Number Type(Required)

Email Address

BANK DRAFT INFORMATION

Bank Draft Amount(Required)

Select a draft option:(Required)

Contribution Type (if applicable):(Required)

Month To Begin Draft(Required)

Note: If the 1st falls on a weekend or holiday, the draft will be on the next business day.

Select draft frequency:(Required)

Multiple Participants

If this draft is for multiple participants, please list their name, account number, amount of contribution, and type of contribution (i.e. pre-tax salary reduction, Roth salary reduction, or employer).

BANK ACCOUNT INFORMATION

Name on Bank Account(Required)

Routing Number(Required)

Bank Account Number(Required)

Please select your account type(Required)

VOIDED CHECK

**If you are updating the amount of your current bank draft only, you do not need to upload a check. If you are updating banking information or submitting a new bank draft, please include a voided check, a copy of check, a picture of a check, or official bank form which includes routing and account number.

Please use bank account information on file

Check Upload

Max. file size: 2 MB.

Please upload a voided copy of your check, a picture of a check, or official bank form which includes routing and account number.

*Note: If any contribution (or any portion of a contribution) is made by a good faith mistake of fact, then within one year after the payment of the contribution, and upon receipt in good order of a proper request approved by the Board of Retirement, the amount of the mistaken contribution (adjusted for any loss in value) shall be returned directly to the participant or, to the extent required or permitted by the Board of Retirement, to the participating employer.

DRAFTING AUTHORIZATION AND AGREEMENT

I hereby authorize the Board of Retirement & Insurance to draft payments electronically from my checking/savings account. To ensure that my account is properly debited, I have attached a voided check, copy of check, picture of a check, or official bank form including routing and account number where my payments will be withdrawn. I acknowledge the monthly bank draft will take place on the date I chose above. I agree that this authorization will remain in effect until I provide notification terminating this service.

Signature(Required)

Please enter todays date (mm/dd/yyyy)(Required)