EFT/Drafting Authorization Form

EFT/DRAFTING AUTHORIZATION AND AGREEMENT

Bank Draft - 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a voided check (or official bank form including routing and account number) from my account where my payments will be withdrawn, and completed the form below. I agree that this authorization will remain in effect until I provide notification terminating this service.*

Direct Deposit - 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, or a deposit slip from my savings account, where my payments will be deposited. I agree that this authorization will remain in effect until I provide notification terminating this service.

Please select a draft or deposit option:

Please select the bank draft or direct deposit frequency:

PERSONAL INFORMATION

Please select your account type

VOIDED CHECK

Please scan in and upload a voided copy of your 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.

SIGNATURE

Use your mouse (or finger if on a mobile device) to sign your name in the box below.