Fillable Printable Direct Deposit Authorization Form - California

Direct Deposit Authorization Form - California

Pension Direct Deposit Form 05_2013

1000 Burnett Avenue, Suite 110 • Concord, CA 94520-2000

Mail: P. O. Box 4102 • Concord, CA 9452

4-4102

Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile: (925) 746-7552

www.ufcwtrust.com

DIRECT DEPOSIT AUTHORIZATION FORM

To initiate Direct Deposit of your monthly pension check, please complete and sign the Authorization Agreement

below:

UFCW – Northern California Employers Joint Pension Plan (Food & Butcher)

UFCW Pharmacists, Clerks and Drug Employers Pension Plan

Retail Clerks Specialty Stores Pension Plan

Please Print Name: _______________________________________________________________

Please print your Social Security number to expedite processing: _______ ‐ _____ ‐ _________ Until your

Direct Deposit service is in place, we will continue to mail your check to your home address. Once your Direct

Deposit is in place, your benefits will be deposited directly to your bank account on the first business day of the

month.

AUTHORIZATION AGREEMENT FOR AUTOMATED DEPOSIT OF PENSION CHECKS

I hereby authorize UFCW & Employers Trust (Hereinafter called “Plan”), to initiate credit entries and to initiate, if

necessary, debit entries and adjustments for any credit entries in error to my account indicated below and the

depository named below, on the voided check, (hereinafter called “Depository”), to credit and/or debit the

same to such account. This authorization is to remain in effect until company has received written notification

from me of its termination in such time and manner as to afford Plan and Depository a reasonable opportunity

to act on it.

Select Only One: Checking* Savings*

*For deposits to your checking or savings account, you must submit either a voided check, a direct deposit set-

up form from your bank (must include your full name and account information), or have a bank

representative complete the section below. Note: a Deposit Slip is not acceptable.

Participant Signature: ___________________________________ Date: ______________

Direct Deposit Set-up - (for Bank Representative’s use only)

Bank ABA: __ __ __ __ __ __ __ __ __ Account #: _________________________________________

Bank Name: ________________________ Phone #: __________________________________________

Address: _____________________________ City__________________ State________ Zip _____________

Bank Representative’s Signature: _________________________________________ Date: ______________