Fillable Printable Direct Deposit Authorization Form - South Carolina
Fillable Printable Direct Deposit Authorization Form - South Carolina
Direct Deposit Authorization Form - South Carolina
Note: If funds are to be deposited into only one account, you MUST select the ALL box. If a PERCENTAGE or DOLLAR AMOUNT is
entered, you MUST provide the secondary account information below for the remaining balance.
Direct Deposit Authorization
SC Public Employee Benefit Authority
South Carolina Retirement Systems
PO Box 11960, Columbia, SC 29211-1960
City
Phone Number with Area Code
Check Payment Type:
First Name/Middle Name
State
Social Security NumberPayee Last Name
Mailing Address Zip Code
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND
THE SOUTH CAROLINA RETIREMENT SYSTEMS. THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
Check if new address
CHECKING
SAVINGS
1. Primary Account Information:
Suffix
Annuity
Refund
TERI Payment
Death Payment
South Carolina Retirement System
Police Officers Retirement System
General Assembly Retirement System
Retirement System for Judges/Solicitors
Accidental Death Program (PORS only)
National Guard Retirement System
Alternate Payee under QDRO (enter MEMBER SSN above)
Member
Beneficiary of deceased member (enter MEMBER SSN above)
Check appropriate system:
Check appropriate box:
Member SSN:
The amount specified below will be directly deposited into this account.
Financial Institution Name Transit/Routing Number Account Number
ALL
OR
You may enter a percentage or dollar amount:
Financial Institution Name Transit/Routing Number Account Number
SAVINGS
CHECKING
(OR mark with "X" with two witnesses OR Power of Attorney, if on file with the Retirement Systems)
(Note: This form must be signed and dated. See notes on Page 2.)
2. Secondary Account Information: The remaining balance will be directly deposited into this account.
Form 7204
Revised 11/14/2013
Sign in Blue ink
TAPE A VOIDED CHECK HERE (No deposit slips or starter checks, please)
TAPE A VOIDED CHECK HERE (No deposit slips or starter checks, please)
Payee's Signature Date
If this account does not have checks, please attach a form from your financial institution certifying the account
and routing numbers.
If this account does not have checks, please attach a form from your financial institution certifying the account
and routing numbers.
Form 7204
Revised 11/14/2013
Page 2
Direct Deposit Authorization
By completing and signing this form, you authorize the South Carolina Retirement Systems to initiate
credit entries, or such adjusting entries (debit or credit), as necessary for corrections to your checking
or savings account. You also authorize the financial institution named to credit or debit the same to such
account. If you close your bank account, please notify our office immediately.
Payment Type
Please complete the Payment Type section in the upper right corner of the form. This will ensure that
your direct deposit information is entered correctly for payment.
Return completed form to:
South Carolina Retirement Systems
P.O. Box 11960
Columbia, SC 29211
If you have any questions or need additional information, please contact the S.C. Retirement Systems' Customer Services
department at 803-737-6800, 800-868-9002 (within S.C. only) or www.retirement.sc.gov.
