Fillable Printable Direct Deposit Authorization Sample Form - Indiana

Direct Deposit Authorization Sample Form - Indiana

STATE OF INDIANA HRA – SB501

980 - DIRECT DEPOSIT AUTHORIZATION FORM

Retiree Name

Retiree SSN

Employer: State of Indiana - Effective Retirement Date: _______________

I hereby authorize and request the Key Family of Companies to initiate credit entries to the account indicated below:

_____ Checking Account _____Savings Account

Account Number

Bank ACH Transit Routing Number

(use the TRN from your Checking Account, not the number on the Savings Deposit Slip)

Depository

(Bank Name)

Branch City State

This authorization will remain in effect until written notice is received by the Key Family of Companies that terminates this authorization.

NOTE: In the event of a bank deposit rejection because the retiree fails to advise KBA of a

change in the banking account utilized for direct deposits, a fee of $30.00 may be assessed.

Signature

Date

IMPORTANT:

CHECKING ACCOUNT – A VOIDED CHECK MUST BE ATTACHED

SAVINGS ACCOUNT – A VOIDED WITHDRAWAL SLIP MUST BE ATTACHED

Please attach a voided check (or withdrawal slip for savings account). If this is not

available you must obtain the correct ACH transit routing number and bank account

number from your bank where you want your reimbursement deposited.

Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC 29716-1179 800-558-5553