EFT/Drafting Authorization Form

EFT or Drafting Authorization

EFT/DRAFTING AUTHORIZATION AND AGREEMENT

Please Select a Payment Option (mark a box)(Required)

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a voided check (or official bank form including routing and account number) from my account where my payments will be withdrawn, and completed the form below.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.

Bank Draft Amount(Required)

Please select a draft or deposit option:(Required)

Please select the bank draft or direct deposit frequency:(Required)

Account Number(Required)

Month To Begin Service(Required)

PERSONAL INFORMATION

Name(Required)

First Middle Last

Social Security Number (No dashes)(Required)

Address(Required)

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

Home Phone Number(Required)

Cell Phone Number

Email Address(Required)

Name on Bank Account(Required)

Name of Bank(Required)

Routing Number(Required)

Street Address of Bank(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 voided check/official bank form. If you are updating banking information or submitting a new bank draft, please include a voided check or official bank form that includes routing and account number.

Please use bank account information on file

Voided Check Scan

Max. file size: 2 MB.

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

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

Signature