Fillable Printable Direct Deposit of Annuity Payments - Pennsylvania

Direct Deposit of Annuity Payments - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA

STATE EMPLOYEES' RETIREMENT SYSTEM

30 N 3RD STREET

SUITE 150

HARRISBURG, PA 17101-1716

TOLLFREE: 1-800-633-5461

www.sers.state.pa.us

DIRECT DEPOSIT OF ANNUITY PAYMENTS

YOUR SS#

INSTRUCTIONS: Complete Part I. Have your Financial Institution complete Part II. This form must be filed with SERS at the address listed above. The

Financial Institution may make a photocopy for their records. A copy will be returned to the payee indicating the effective date of the new direct deposit. Your

monthly annuity payment will be credited to your account and be available for use on the last working day each month. NOTE: After this form is processed,

your first monthly check will be mailed to your home address. The second and subsequent checks will be electronically deposited in your new direct deposit

account .

* KEEP SERS INFORMED OF YOUR CORRECT HOME ADDRESS *

PART I - PAYEE AGREEMENT

NAME: FIRST MIDDLE LAST

MEMBER'S SS#

STREET ADDRESS

TELEPHONE NUMBER

CITY STATE ZIP CODE

TYPE PAYEE

MEMBER

(check one)

SURVIVOR

ALTERNATE PAYEE

ACTION TO BE TAKEN (CHECK ALL THAT APPLY)

START DIRECT DEPOSIT

STOP DIRECT DEPOSIT

CHANGE FINANCIAL INSTITUTION CHANGE ACCOUNT NUMBER

I hereby authorize and request the Pennsylvania State Employees' Retirement System (SERS) to direct

the net amount of my monthly benefit checks for crediting to my account indicated at the Financial

institution designated below, and I further authorize the Financial Institution to credit the same to such

account without responsibility for correctness of such amount. I hereby revoke all prior payment

arrangements with SERS.

This authorization will remain in effect until I give written notice of its termination to SERS in such time and

in such manner as to allow SERS a reasonable opportunity to act upon it. I agree to notify SERS if I wish

to change the designated Financial Institution or account to which my net pay is to be deposited sixty (60)

days prior to the effective date of such change.

PAYEE - STOP HERE!

(Have your financial institution complete the remainder of this form.)

PART II - FINANCIAL INSTITUTION AGREEMENT

*** DO NOT WRITE - SERS USE ONLY ***

This change will be effective ____________

PAYEE'S SIGNATURE

DATE



ACH ROUTING NUMBER ACCOUNT NUMBER

ACCOUNT TYPE (CHECK ONE)

CHECKING SAVINGS

If an account type is not selected, the benefit cannot be processed.

FINANCIAL INSTITUTION

NAME

DATE:

STREET ADDRESS

TELEPHONE NUMBER

CITY STATE ZIP CODE

TITLE:

In consideration of SERS making payments in accordance with this authorization without requiring other proof that the payee is alive on the date which

such payment falls due, we hereby agree to repay, refund and/or reimburse to SERS, on demand, the amount of payments made to and received by us,

the due date of which shall be after the date of death of the payee, to the extent that funds representing such payments remain on deposit with the

financial institution at the time of certification of Payee's death by SERS, to the financial institution.

AUTHORIZED SIGNATURE

SERS-123 (Rev. 9/2012)