Fillable Printable Direct Deposit Sign-up Form - Maryland

Direct Deposit Sign-up Form - Maryland

SECTION I

To Be Completed by Payee

Directions for Payee:

1) Please read the instructions printed on the following page.

2) Complete SECTION I.

3) Provide this form to your financial institution so that they may

complete Section II.

* Advise the Maryland State Retirement Agency (SRA) of

change of home address to receive important information

regarding benefits and taxes.

A. SOCIAL SECURITY NUMBER OF PAYEE

—

NAME OF PAYEE (last, first, middle initial)

ADDRESS (street, route, P.O. Box, APO/FPO)

CITY STATE ZIP CODE + 4

AREA CODE TELEPHONE NUMBER

NAME AND ADDRESS OF FINANCIAL INSTITUTION:

AUTHORIZED REPRESENTATIVE’S SIGNATURE:

PRINT/TYPE REPRESENTATIVE’S NAME AND TITLE:

AREA CODE/TELEPHONE:

DATE:

If you are receiving more than one payment from the

SRA please indicate which payment this EFT applies to:

RETIREE BENEFICIARY ALL

DATE THAT ELECTRONIC FUND TRANSFER

SHOULD BEGIN.

Check here only if your entire payment amount is subject

to being transferred to a foreign bank account. See

reverse side for more information.

PAYEE AUTHORIZATION

By signing my name below, I certify that I am the payee iden-

tified above, and hereby authorize SRA to deposit my

allowance into my account at my financial institution. I certify

that I am the account holder of the account indicated on this

form, and the account is not in the name of a trust. I authorize

and direct the financial institution, on my behalf, on behalf of

my joint account holder, if any, and my estate to charge my

account for any amounts paid to which I am not entitled and

to return any overpayments to SRA. I also authorize the

release by the bank or financial institution of my current

address, names and current addresses of all persons listed

on the account, including, but not limited to those listed as

“payable on death” or “transfer on death” to SRA.

Signature of Payee Date

Signature of Joint Holder (if any) Date

SECTION II

To Be Completed by Financial Institution

Directions for Financial Institution:

1) Verify information in SECTION I.

2) Complete SECTION II.

3) Send completed form to:

Maryland State Retirement Agency

ATTN: EFT Department

120 East Baltimore Street

Baltimore, MD 21202-6700

or fax to: EFT Department at 410-468-1700

ROUTING NUMBER CHECK

DIGIT

TYPE OF ACCOUNT SRA USE

Place “X” in only one box ONLY

CHECKING ACCOUNT 22

SAVINGS ACCOUNT 32

FINANCIAL INSTITUTION CERTIFICATION

I confirm the identity of the named payee(s) and certify

that the payee’s name appears on the account provided

in SECTION H. above. As a representative of this finan-

cial institution, I certify that the financial institution agrees

to receive and deposit the payment as identified. The

financial institution agrees to return all benefits received

after it learns of the death of the individual or if the

account is closed for any reason.

PAYEE’S ACCOUNT NUMBER

MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

DIRECT DEPOSIT — ELECTRONIC FUNDS TRANSFER SIGN-UP FORM

RETIREMENT USE ONLY Form 85 (REV. 1/15)

If you need assistance in completing this application, telephone a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.

Important: The payee’s name must appear on the account

VSP

MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

PLEASE READ THIS CAREFULLY

All information on the reverse side of this form, including the individual Social Security

number, is required. The information is confidential and will be used only to process payment data

from the Maryland State Retirement Agency to the financial institution and its agent. Failure to

provide the requested information may prevent the receipt of payments through the Electronic

Funds Transfer Program.

Special Notice to Joint Account Holders

Joint account holders should immediately advise both the Maryland State Retirement Agency

and the financial institution of the death of the Maryland State Retirement Agency payee. Funds

deposited after the date of death are to be returned to the Maryland State Retirement Agency. The

Maryland State Retirement Agency will then make a determination regarding survivor rights, and

process survivor benefit payments, if any.

Cancellation

The agreement presented by this authorization remains in effect until cancelled by the

recipient by notice to the Maryland State Retirement Agency. Upon cancellation by the recipient,

that recipient should notify the receiving financial institution that he/she is doing so.

The agreement represented by this authorization may be cancelled by the financial institution

by providing the recipient a written notice 30 days in advance of the cancellation date. The

recipient must immediately advise the Maryland State Retirement Agency if the authorization is

cancelled by the financial institution. The financial institution cannot cancel the authorization by

advice to the Maryland State Retirement Agency.

Changing Receiving Financial Institutions

The payee’s Electronic Fund Transfer arrangement will continue until the Maryland State

Retirement Agency is notified by the payee that the payee wishes to change the financial

institution receiving the Electronic Funds Transfer. To effect this change, the payee will complete

a new FORM 85 form. The payee should maintain accounts at both

financial institutions

until the transition is complete, i.e. after the new

financial institution receives the payee’s

Electronic Funds Transfer payment.

International Automated Clearing House Transaction Rules

Electronic payments to your designated account must comply with the provisions of U.S. law,

as well as the requirements of the Office of Foreign Assets Control.

If you receive your monthly retirement benefit via direct deposit at a U.S. bank and then

you have the entire benefit amount forwarded to a foreign bank (a bank located in a country

outside the United States), please check the box labeled F on the front side of this form.

sra.maryland.gov