Direct Deposit Authorization Form

Direct Deposit 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

DIRECT DEPOSIT INFORMATION

Direct Deposit Amount(Required)

Select deposit type:(Required)

Month To Begin(Required)

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

Select draft frequency:(Required)

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 banking information or submitting a direct deposit form, please include a voided check, a copy of check, a picture of a check, or official bank form which includes routing and account number.

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 deposit payments electronically into my checking/savings account and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account. To ensure that my account is properly credited, I have attached either a voided check from my checking account, official bank form including routing and account number, a copy/picture of check, or a deposit slip from my savings account, where my payments will be deposited. I acknowledge that the direct deposit will take place on the first business day of each month. 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)