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 expediteprocessing: _______ ‐ _____ ‐_________ Untilyour

Direct Deposit service is inplace, we will continue to mail your checkto your home address.Once your Direct

Deposit is in place, your benefits willbe deposited directly to yourbank accounton the first business day ofthe

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 tomy account indicated below and the

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

same to suchaccount. This authorization is to remain ineffect 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 andaccount information),or have a bank

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

ParticipantSignature: ___________________________________ 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: ______________