Fillable Printable Authorization for Direct Deposit of Retirement Benefit - Massachusetts

Authorization for Direct Deposit of Retirement Benefit - Massachusetts

AUTHORIZATION FOR DIRECT DEPOSIT

THIS SECTION BOARD USE ONLY

THE COMMONWEALTH OF MASSACHUSETTS

State Retirement Board

05/2015

AUTHORIZATION FOR DIRECT DEPOSIT OF

RETIREMENT BENEFIT

SECTION A (required)

Name:

Address:

City: State: Zip:

Phone: Email:

SS# Member ID (if known):

SECTION B (required)

Name of Financial Institution:

All Names on Account:

Routing #:

Depositor Account #:

Please Check Appropriate Box: Savings Account Checking Account, voided check attached

Are you receiving direct deposit in this account as an active employee of the Commonwealth? Yes No N/A

PLEASE INCLUDE A VOIDED CHECK IF BEING DEPOSITED INTO A CHECKING ACCOUNT

Check box if any of the above direct deposit will go directly to a foreign bank or if the entire amount is forwarded from a

domestic bank to a foreign bank.

PLEASE SIGN BELOW (required)

“I, ___________________________________________hereby authorize the State Treasurer to deposit my

retirement benet into my account at the nancial institution named above. The State Treasurer is also

authorized to debit or credit my account, to adjust any over deposit which it has caused to be made to my

account. This authorization will remain in eect until revoked by me with thirty (30) days written notice to the

Treasurer and Receiver General, One Winter Street, 8th Floor, Boston, MA 02108, or by the State Treasurer.

I certify that I am the person entitled to receive the payment under this application. I also certify that the

information herein provided is accurate to the best of my knowledge.”

Signature Date

| Faxing Direct Deposit Form? Send to our Boston oce: 617-723 -1438

Direct Deposit is mandatory for all members retiring after January 1, 2010.

Statements can be viewed online at mass.gov/payinfo

If sending voided check, please do not staple to this form.

*DIRECT DEPOSIT*