Direct Deposit Authorization Form Page 3
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4Clear Form
Plumbers & Pipefitters National Pension Fund
Form #61
103 Oronoco Street, Alexandria, Virginia 22314-2047
(Rev. 04/15)
Direct Deposit Authorization Form
To sign up for Direct Deposit, the Payee/Account Holder must complete the information below. All
holders/parties on the account must read and sign the authorization agreement on the back of this
form.
The Payee/Account Holder must have a Bank Employee verify the bank account and
account holder information below. Mail this completed form (both sides), with your pre-printed
voided check or savings account deposit slip attached, to the Fund at the above address.
Payee/Account Holder _________________________________________ S.S.#. _______---______---_________
Address _____________________________________________________________________________________
S
C
S
Z
C
TREET
ITY
TATE
IP
ODE
Telephone Number ___________ — ___________ — _______________
Check here if new address
I
O
/
A
.
DENTIFY ALL
THER SIGNERS
PARTIES ON THE
CCOUNT
U
O
Holders/Parties.
SE SPACE BELOW AND ATTACH A LIST WITH SAME INFORMATION FOR ADDITIONAL
THER
C
O
A
H
.
HECK HERE
IF THERE ARE NO
THER
CCOUNT
OLDERS
Other Signer/Party ___________________________________________
S.S.# _______---______---_________
Address _____________________________________________________________________________________
S
C
S
Z
C
TREET
ITY
TATE
IP
ODE
Telephone Number ___________ — ___________ — _______________
Relationship to Payee/Account Holder __________________
A
H
H
/P
,
,
CCOUNT
OLDER AND ALL OTHER
OLDERS
ARTIES
IF ANY
MUST READ AND SIGN THE AGREEMENT ON THE REVERSE SIDE OF THIS FORM
THIS FORM CANNOT BE PROCESSED WITHOUT VERIFICATION FROM THE BANK. If you are utilizing internet
banking, please provide account holder(s) name, account & routing number on the bank’s letterhead,
including signature and title of bank employee. This information can be obtained through the bank’s
customer service department.
Bank Name _________________________________________ Transit # ___ ___ ___ ___ ___ ___ ___ ___ ___
Bank Mailing Address for Deposits of paper checks
________________________________________________________________________________
S
PO B
#
C
S
Z
C
TREET OR
OX
ITY
TATE
IP
ODE
Branch Telephone Number ___________ — ___________ — _______________
Account Number ____________________________________________________
Type of Account –
Personal Checking –
Trust Account
Personal Savings (
MUST NOT BE A BUSINESS OR
)
INSTITUTION
A V
P
-P
P
C
O
P
-P
P
S
A
D
S
MUST B
A
OIDED
RE
RINTED
ERSONAL
HECK
R
RE
RINTED
ERSONAL
AVINGS
CCOUNT
EPOSIT
LIP
E
TTACHED
I certify that the above bank account and account holder information is correct and complete.
Bank Employee
_________________________________________ Title ________________________
(P
N
)
RINT
AME
Bank Employee Signature ___________________________________________ Date _______________________
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