Authorization For Direct Deposit Form 4-05 - Lasers
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1
2Form 4-05
R050217
Payee Type:
P.O. Box 44213, Baton Rouge, LA 70804-4213
Retiree
225.922.0600 · Toll-Free 1.800.256.3000
Beneficiary/Survivor/Alternate Payee
Fax 225.935.2856
Authorization for Direct Deposit
Member's First Name
Middle Name
Last Name
Today's Date
Social Security Number
SECTION 1: BENEFIT RECIPIENT INFORMATION
Payee's Name
Date of Retirement (new retirees)
Social Security Number
Payee's Mailing Address
City
State
Zip Code
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
E-mail Address
No
Yes
Would you like your address changed to the above?
SECTION 2: ACCOUNT INFORMATION
Check at least one:
Benefit Type:
Monthly Retirement Benefit
DROP/IBO Withdrawal
Name and Address of Financial Institution
Type of Account:
Checking
Savings
Routing Number (9 digits)
Account Number (up to 17 digits)
Name of Joint Account Holder (if applicable)
Social Security Number
SECTION 3: PAYEE AND JOINT ACCOUNT HOLDER'S SIGNATURE
I hereby authorize the Louisiana State Employees' Retirement System (LASERS) to direct the net amount of my monthly benefit payment
to my account at the financial institution designated above. This authorization is not an assignment of my right to receive payment and
revokes all prior payment direction notifications applicable to these payments. Upon my death, if payments have been deposited to my
account that are not due, or if funds are credited to my account in error for any reason, I authorize: 1) LASERS to initiate electronic funds
transfer debit transactions to retrieve those payment; and 2) The financial institution (bank or credit union) to release to LASERS the status
of my account, my current mailing address, the names and mailing addresses of any joint account holder, and the names and mailing
addresses of individuals who have power of attorney relevant to those payments to withdraw funds from my account. If my death should
occur prior to the due date of any payment which is made by LASERS in compliance with the Authorization for Direct Deposit, the named
financial institution shall refund such payments to LASERS. I certify that I am entitled to the payment identified herein. Any joint signer,
listed below, on the bank account accepts the responsibility of notifying LASERS of the death of the named Payee, and agrees to accept full
responsibility for returning any funds to LASERS which were transmitted by LASERS to the account after the death of the Payee.
By signing below, you certify that you have read the provisions of this form, and fully understand the obligations contained herein.
Payee's Signature
Date
Joint Account Holder's Signature
Date
Reset Form
4-05 R
RETAIN A COPY FOR YOUR RECORDS
ERBER11 Page 1 of 1
050217
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