Fillable Printable Direct Deposit Authorization - Alabama

Direct Deposit Authorization - Alabama

Direct Deposit Authorization

Retirement Systems of Alabama

The retiree or beneficiary of a deceased retiree must complete Sections A, B, and C of this form. Then take or mail the form to

your financial institution to verify the information in Sections A, B and C, complete Sections D and E, and agree to the Master

Agreement.

Section A: Benefit Recipient Information

Social Security Number ____________________________________ Benefit Recipient (Please check one):

 Retiree

 Beneficiary of Deceased

Retiree/Member

Name _________________ ___________________________________

Address _______________ ___________________________________ Daytime Phone No. ________________

__________________________________________________________ Email Address ____________________

__________________________________________________________

Indicate the system(s) from which you would like your benefit(s) direct deposited.



Teachers’ Retirement System



Employees’ Retirement System



PEIRAF



Judicial Retirement Fund



RSA-1 (Annual or Monthly Distribution Only)

Section B: Joint Financial Institution Account Holder’s Certification

I agree to notify the Retirement Systems of Alabama (RSA) immediately of the death of the recipient of the retirement benefits

being deposited to this joint financial institution account, and to return all payments to the RSA that are deposited to this

account after said death. The RSA will determine and pay any survivor benefits. The RSA is authorized to make necessary

debit entries to this joint account for any credits that were made in error.

Name(s) of Joint Financial Institution Account Holder(s)

Signature(s) of Joint Financial Institution Account Holder(s)

Date ____________________________________

Section C: Benefit Recipient Certification

Each benefit payment is to be credited to my account at the financial institution specified on the reverse side of this form and

such payment will be in full payment, satisfaction, and discharge of the amount then falling due and payable to me on account

of such payments.

If my death occurs prior to the due date of any payment made by the RSA in compliance with this request or if adjustments are

required for any credit entries to my account, I authorize the RSA to make the necessary debit entries to my account. I hereby

reserve the right to revoke or cancel this request, such revocation or cancellation to take effect within 30 days of receipt of

written notice by the RSA.

I authorize my payment to be sent to the financial institution named on the reverse side of this form to be deposited to the

designated account.

Signature of Benefit Recipient __________________________________________ Date ______________________

RSA DDR (06/13)

P.O. Box 302150

Montgomery, Alabama 36130-2150

334-517-7000 or 877-517-0020

www.rsa-al.gov

Section D: Financial Institution Information (To be completed by a representative of the financial

institution)

Name of Benefit Recipient ________________________________________ Soc. Sec. No. ____________________

Depositor Account No. __________________________________ Bank Routing No. _________________________

Name of Financial Institution ____________________________________________ Type of Account:  Checking

 Savings

Mailing Address ____________________________________________________________

__________________________________________________________________________

Name(s) of Person(s) on this Account: __________________________________________________

__________________________________________________

Section E: Financial Institution Certification and MASTER AGREEMENT

In accordance with the provisions of Section 3.6.4 of the 2012 National Automated Clearing House Association

(NACHA) Operating Rules and Guidelines, both the Retirement Systems of Alabama (RSA), as the Originator, and the

above named Financial Institution consider the following to be the Master Agreement, as defined by the NACHA

Operating Rules and Guidelines, and agree that it is to be applicable to all payments sent by the RSA to the Financial

Institution for the benefit of all benefit recipients having accounts with the Financial Institution.

In consideration of the RSA making benefit payments in accordance with this Direct Deposit Authorization without

requiring proof that the retiree/beneficiary identified on this form is alive on the date on which such benefits are paid

and are credited to his or her account, the Financial Institution agrees to repay and refund to the RSA, on demand, the

full amount of any payments made to and received by the Financial Institution after the date of death of the benefit

recipient, regardless of whether the account listed on this Direct Deposit Authorization contains sufficient funds for the

refund. The Financial Institution further agrees to accept the certification of the RSA as to the date of death of such

payee as sufficient evidence in accordance with Section 2.10 of the 2012 NACHA Operating Rules and Guidelines.

I, the undersigned, confirm that the identity of the above named retiree/beneficiary, account number, and type are true

and accurate. As the representative of the above named Financial Institution, I certify that the Financial Institution

agrees to receive and deposit the identified payments in accordance with the Master Agreement and pursuant to

Section 3.6.4 of the 2012 NACHA Operating Rules and Guidelines, and that the Master Agreement is applicable to all

payments sent by the RSA to the Financial Institution for the benefit of the retiree/beneficiary.

Name of Representative _________________________________________________

Signature of Representative ______________________________________________ Date ___________________

Telephone Number _____________________________________________________

Please return completed form to:

The Retirement Systems of Alabama

P.O. Box 302150

Montgomery, Alabama 36130-2150

Note: Direct Deposit Authorization forms that are processed after the 14th of each month will become effective the following month.