Form C4 - Application For Normal Retirement - 2011 Page 16
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22Form 13
PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM
08/11
CORRECTIONS OFFICER RETIREMENT PLAN
ELECTED OFFICIALS' RETIREMENT PLAN
Fax OR Mail form to:
3010 East Camelback Road, Suite 200
Non-retired Fax
Phoenix, Arizona 85016-4416
(602) 296-2368
(602) 255-5575
Retired Fax
(602) 296-2369
AUTHORIZATION TO START OR CANCEL DIRECT DEPOSIT
Section 6109 of the Internal Revenue Code mandates disclosure of your Social Security number (SSN). We will only use your SSN to
obtain account information and to inform the Internal Revenue Service (IRS) of distributions and withholdings.
SECTION 1 – PRINT Information
SSN
Status (check one)
Retired
Survivor/Guardian
Ex-spouse
Refunding
RETIREE SYSID (if known)
Date of Birth (MM/DD/YYYY)
Gender (Check One)
If ex-spouse, provide member’s name:
Male
Female
Name (Last)
(First)
(Middle)
Address – City, State, ZIP Code +4
E-mail Address
Home Telephone #
Cell #
Work #
(
)
(
)
(
)
SECTION 2 – Bank Information -
If you have more than one account, complete a new form for each account.
I authorize the deposit of my check(s) into the following account (replacing all prior requests):
Check only one:
Checking
OR
Savings
Routing # and account # samples:
Routing # (9 digits):
Account # :
Financial Institution:
ATTACH A VOIDED CHECK (or copy) ON REVERSE SIDE
(or a letter from your financial institution verifying your name, account and routing numbers)
AND COPY OF YOUR DRIVER’S LICENSE (or ID card)
SECTION 3 – Cancellation of Direct Deposit
STOP
ONLY check this box if you want to
the direct deposit entirely and send your check(s) to your mailing address.
SECTION 4 – REQUIRED Signature
- If not previously provided and signing as a Power of Attorney or Guardian, provide our
office with a complete copy of the appointment documentation.
By my signature below, I authorize and understand that:
-
The financial institution stated above will debit my account for the purpose of error corrections (upon written request to the financial
institution by the PSPRS/CORP/EORP).
-
Upon written request by the PSPRS/CORP/EORP, the financial institution stated above will release my address and/or general account
information to the PSPRS/CORP/EORP. For example, this includes the name and address of any joint account holder(s), or legal
representative(s) on the account.
-
Any joint bank account holder(s) must immediately notify the financial institution and the PSPRS/CORP/EORP of the death of the
member and must also return to the PSPRS/CORP/EORP any deposited funds that the member is not entitled to receive.
-
This agreement remains in effect until canceled by me, in writing, or upon my death. The PSPRS/CORP/EORP reserves the right to
discontinue or cancel this deposit at any time.
REQUIRED Signature
Date
th
We must receive a properly completed form by the 10
of the month in order to be processed that month.
For account information, visit our website at
under “Members Only.”
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