Direct Deposit Request Form - Franklin Regional Retirement System printable pdf download

FRANKLIN REGIONAL RETIREMENT SYSTEM

278 MAIN STREET, SUITE 311 GREENFIELD, MASSACHUSETTS 01301-3230

TELEPHONE: 413-774-4837

FAX: 413-774-5677

Direct Deposit

Mandatory for All Retirees

Instructions: Please fill in the following information and return this form, along with a voided check or

copy of bank statement for a checking or savings account of your choice, to the above address. You will

receive a “Notice of Deposit” the first month you receive a benefit, in the months of July and December,

and any other month in which a change to your benefit occurs.

Please check one:

New

Change

I, _________________________________ request and authorize the Franklin Regional Retirement System, to make

a direct deposit of my net retirement pay to the below named bank and indicated account, by initiating a credit entry

for any amounts owing to me. I understand that my net retirement pay will be credited to my account on the

30th of each month or the last business day prior to the 30

if the 30

falls on a weekend or holiday.

Bank Name:

___________________________________________________

Address

___________________________________________________

City

State

Zip

Account Information

ABA(bank) No. _________________________ Account (you)No. ___________________________

Please check one:

Checking

Savings

In addition, please attach a copy of a check for checking or a copy of bank statement for savings.

I agree that if the Franklin Regional Retirement System credits an unearned or erroneous payment to my account, I

will immediately repay the Franklin Regional Retirement System the full amount of such unearned or erroneous pay.

I further agree that if I do not repay such unearned pay, I will be personally liable for all costs of collection,

including reasonable attorney’s fees incurred by the Franklin Regional Retirement System in the collection of such

unearned pay, together with the maximum interest or late charges permitted by law.

Retiree Signature: ___________________________ Last Four of Social Security No.: ____________

Date: ______________

N:\USERS\FORMS\Direct Deposit request Form.doc; Last printed 06/26/2014 12:26:00 PM; Last saved by Patty Leveille

Direct Deposit Request Form - Franklin Regional Retirement System