Authorization Agreement For Automatic Direct Deposit Form - City Of Pontiac, Michigan
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1CLEAR FORM
City of Pontiac, Michigan
General Employees Retirement System
Police and Fire Retirement System
AUTHORIZATION AGREEMENT FOR AUTOMATIC DIRECT DEPOSIT
Please read this form carefully and write clearly.
For automatic direct deposit you must:
1. Already have the account set up at your bank.
2. Find out if they accept direct deposits. Verify the bank’s transit # (TBA) and your account #.
3. Notify the bank that you are going to set up direct deposit through Retirement. Make sure that
there are no special procedures to do at the bank.
Please return this form to the Retirement Office with a voided check from your checking account or a deposit
form from your savings account to Retirement Office, 47450 Woodward Ave., Pontiac, MI 48342.
Please check the appropriate action and fill out all accompanying information:
_____ A new account or
_____ A new account to replace a direct deposit already set up
st
1
Bank Name ___________________________
Bank Account # ________________
Bank TBA # _ _ _ _ _ _ _ _ _
/ Checking ___ Saving ___ / Full Deposit ___ or Partial $______
nd
2
Bank Name ___________________________
Bank Account # ________________
Bank TBA #
_ _ _ _ _ _ _ _ _
/ Checking ___ Saving ___ / Full Deposit ___ or Partial $______
_____ Canceling account
Account # ________________________________
_____Direct deposit already set up, changing $ amount only
Account # ___________________________
Full Deposit ___ Partial Deposit $_______
I authorize the Pontiac Retirement System, ADP and the bank(s) herein listed to deposit my pay as indicated
above into my account each payday.
I will not close an account without first notifying the retirement office.
If funds to which I am not entitled are deposited to my account, I authorize the Pontiac Retirement System and
ADP to direct the bank to return said funds.
I understand that my deposit may not be credited to my account until 5:00 p.m. on the pay date indicated on the
pay voucher.
I UNDERSTAND THAT IN ODER TO ALLOW TIME FOR ADP TO VERIFY THE ABOVE INFORMATION, THE
FIRST PAYMENT THAT I RECEIVE AFTER SETTING UP OR CHANGING MY ACCOUNT WILL BE A
CHECK THAT I WILL NEED TO DEPOSIT. SUBSEQUENT PAYMENTS WILL BE DEPOSITED INTO MY
ACCOUNT.
Retiree Signature:
Retiree Name (Printed):
Date:
XXX-XX-
Social Security No:
Please record last 4 digits of social security number
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