Form Da - Pensioner'S Direct Deposit Authorization Form - State Of Delaware
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1State of Delaware
Form DA (Rev 4/1/13)
New Address
Pensioner’s Direct Deposit Authorization Form
Name ____________________________________ Social Security # ____________________________ Employee ID _____________
Address ___________________________________________
City , State, ZIP+4 ______________________________________
This form will override all previous forms. Please list ALL accounts where you wish to have monies deposited.
We no longer require verification in the form of a voided check or bank statement. However, please be aware that YOU
ARE RESPONSIBLE for ensuring that the routing and account numbers on this form are correct. Please contact your
bank to confirm routing/account numbers if you are unsure.
INCORRECT ROUTING AND/OR ACCOUNT NUMBERS WILL RESULT IN YOUR DIRECT DEPOSIT BEING
DELAYED UNTIL THE NEXT SCHEDULED PENSION PAYMENT.
To have your net Pension amount go to ONE account or to have the majority of your monthly Pension amount go to a primary
account (with specific dollar amounts going to additional accounts listed below), complete the following:
Deposit Net Monthly Pension
Routing #
Account
#
CHECK ACCOUNT TYPE:
_________________
_________________
Checking
Savings
Amount into this account.
OR
Bank Name _____________________________________________________________________________
Use this account as primary
with additional monies going
Bank Address _____________________________________________________________________________
to accounts listed below.
If you are using this form to change an existing direct deposit to a primary account and wish to have
ALL other additional deposits (i.e. savings account deposits and/or credit union deposits) remain the same,
Please check one
Continue additional deposits
OR
Stop additional deposits and deposit all monies into the above account
To have a specific dollar amount go to additional banks or credit unions, complete as many of the following as necessary:
CHECK ACCOUNT TYPE:
Deposit the Following $ Amount
Routing #
Account #
_________________
___________________
_________________
Checking
Savings
Bank
Name _____________________________________________________________________________
Bank
Address _____________________________________________________________________________
_________________________________________________________________________________
Deposit the Following $ Amount
Routing #
Account #
CHECK ACCOUNT TYPE:
_________________
___________________
_________________
Checking
Savings
Bank
Name _____________________________________________________________________________
Bank
Address _____________________________________________________________________________
I understand that my monthly benefit amount will be direct deposited to the account(s) designated above so that the funds are
available to me on the last working day of each month.
_________________________________________
_________________________
____________________
Signature of Pensioner or Power of Attorney
Telephone Number
Date
Return form to the Office of Pensions, McArdle Building, 860 Silver Lake Blvd., Suite 1, Dover, DE 19904-2402 or
fax completed form to (302) 739-6129. If you have any questions, call the Pension Office at (302) 739-4208 or (800) 722-7300.
NOTE: If you move and the “Direct Deposit Advisory Notice” or other mailings are returned undeliverable by the Post Office,
your electronic funds transfer authorization will be terminated and the funds held until a signed change of address has been
received by the Pension Office.
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