D
D
E
A
F
IRECT
EPOSIT
MPLOYEE
UTHORIZATION
ORM
E
,
P
D
A
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 System716 Richard Arrington Jr. Blvd N, Suite 430 Birmingham, Alabama 35203 205.325.5354