DIRECT DEPOSIT AUTHORIZATION
ARLINGTON COUNTY EMPLOYEES' RETIREMENT SYSTEM
2100 CLARENDON BOULEVARD – SUITE 511
ARLINGTON, VIRGINIA 22201
TELEPHONE: (703) 228-3500, (800) 818-4910
FAX (703) 228-3265
1. Social Security Number (last 4 digits only)
2. Name (First)
(MI)
(Last)
3. Home Address
4. City
State
Zip Code
5. REQUIRED PRIMARY Account (where you want your net pay to be deposited)
I hereby authorize the Arlington County Employees’ Retirement System to initiate credit entries
to my (check one) Checking ___________ Savings ___________ account indicated below and
2
the bank/savings & loan/credit union to credit the same to such account. This authority is to
remain in full force and effect until the Retirement System has received written notification from
me of its termination.
5a. Name of Bank/Savings & Loan/Credit Union
5b. Bank Transit/Routing Number (9 Digit #)
5c. Bank Account Number
6. OPTIONAL SECONDARY Account (where you want a portion of your net pay deposited. For
example, if you want $100 to be deposited to the Arlington Credit Union.)
I hereby authorize the Arlington County Employees’ Retirement System to initiate credit entries
in the amount of $ _________________OR __________% to my (check one:)
Checking
Savings account indicated below and the bank/savings & loan/credit union to credit the same to
such account. This authority is to remain in full force and effect until the Retirement System has
received written notification from me of its termination.
6a. Name of Bank/Savings & Loan/Credit Union
6b. Bank Transit/Routing Number (9 Digit #)
6c. Bank Account Number
7. Signature
8. Date
9. Your Telephone #
PLEASE ATTACH A VOIDED CHECK HERE
A voided check is necessary to verify the Bank Transit Number & Your Account Number.
If your Direct Deposit goes to a checking account, this form will be returned to you if a voided check
is not provided. (Please do not attach deposit slips)
Direct Deposit may be made to a checking account OR a savings account. If you elect to use a
savings account for the Direct Deposit, it is not necessary to attach a voided check – just provide us
with the bank routing number and your bank account number, both available from your bank.