Direct Deposit Employee Authorization Form printable pdf download

Direct Deposit Employee Authorization Form

IRECT

EPOSIT

MPLOYEE

UTHORIZATION

ORM

VERY FIELD MUST BE COMPLETED

ANY MISSING INFO WILL DELAY THE

ROCESS FOR DIRECT

EPOSIT

CTIVATION

I authorize The General Retirement System for Employees of Jefferson County (hereafter referred to as “GRS”) to direct deposit

funds to my account with the financial institution listed below. If funds to which I am not entitled are deposited in my account, I

authorize the initiation of a correction (debit) entry electronically or by any other commercially accepted method. I understand

that the authorization may be rejected or discontinued at any time. If any of the below information changes, I will promptly

complete a new authorization agreement. If the direct deposit is not stopped before closing an account, funds payable to me will

be returned to you for distribution. This will delay your check.

(Type of Account: please check one)

Checking (voided check)

Savings (letter from financial institution)

Financial Institution Name

(NAME OF BANK)

City:

State:

Zip:

Phone:

I understand that by submitting this form means my entire pension check will be deposited into the above institution. This authorization will be

in effect until “GRS” receives a written termination notice:

Employee Signature

Date

Print First, Middle Initial and Last Name

Social Security Number

Sworn to and subscribed before me this_____________________ day of ____________________________, 20___________.

____________________________________________

Notary Public

PLEASE ATTACH YOUR VOIDED CHECK OR DEPOSIT SLIP IN THIS AREA

General Retirement System716 Richard Arrington Jr. Blvd N, Suite 430  Birmingham, Alabama 35203  205.325.5354

Direct Deposit Employee Authorization Form