Calpers Direct Deposit Authorization Form
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1
2Direct Deposit Authorization
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (800) 959-6545
•
•
Information About You
Section 1
A separate form must
You will receive a confirmation letter with the effective date once CalPERS has processed this completed form. You
be completed for each type of
can review your statement online or receive it by mail from the California State Controller’s Office. In order to receive
retirement benefit to be sent
important information about benefits, payees should keep CalPERS informed of any address changes.
by Direct Deposit.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
Address
Daytime Phone
City
State
ZIP Code
Information About Your Account
Section 2
Checking
Savings
Individual
Joint
Trust Account
*
If you are authorizing your
c
c
c
c
(If so, Complete Section 3)
c
payment to your savings
account or do not have
Routing Number (nine digits)
Account Number
pre-printed, personalized
checks, please have
Please use tape to attach your voided, pre-printed personalized check. (Do not staple or paper clip. No deposit slips.)
your financial institution
(
)
complete this section.
Name of Financial Institution
Branch Phone Number
*
Trust Accounts
Address
You will need to complete
a CalPERS trust form,
which can be obtained
City
State
ZIP Code
by contacting CalPERS.
You confirm the identity of the above-named payee and the account number. As a representative of the above named
financial institution, you certify the financial institution agrees to receive and deposit the payment identified above.
Signature of Representative
Print Representative’s Name
Date (mm/dd/yyyy)
Information About Joint Account Holder (If applicable)
Section 3
Name
Social Security Number or CalPERS ID
(
)
Address
Daytime Phone
City
State
ZIP Code
PERS-BSD-1199P (11/11)
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