Form Rsa Ddr - Rsa Direct Deposit Authorization - Alabama
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2RSA Direct Deposit Authorization
Retirement Systems of Alabama
PO Box 302150, Montgomery, Alabama 36130-2150
877.517.0020 • 334.517.7000 •
*RSA DDR//1/*
Your SSN
Check One: q Retiree q Beneficiary of Deceased Retiree/Member
Your
Name __________________________________________________________________________________________
Information
First
Middle/Maiden
Last
No initials please
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Daytime Telephone ___________________________ Email Address _________________________________________
(
)
Date of Birth ________________________________
Indicate the system(s) from which you would like your benefit(s) direct deposited.
q Employees’ Retirement System
q Teachers’ Retirement System
q PEIRAF
q Judicial Retirement Fund
q RSA-1 (Annual or Monthly Distribution Only)
Account Holder
I agree to notify the Retirement Systems of Alabama (RSA) immediately of the death of the recipient of the retirement benefits being
Certification
deposited to this joint financial institution account, and to return all payments to the RSA that are deposited to this account after
said death. The RSA will determine and pay any survivor benefits. The RSA is authorized to make necessary debit entries to this joint
account for any credits that were made in error.
Joint Financial Institution Account Holder(s) Name(s)
Joint Financial Institution Account Holder(s) Signature(s)
Date ____________________________________________
Signature
Certification
Each benefit payment is to be credited to my account at the financial institution specified on the reverse side of this form and such
payment will be in full payment, satisfaction, and discharge of the amount then falling due and payable to me on account of such
payments.
If my death occurs prior to the due date of any payment made by the RSA in compliance with this request or if adjustments are
required for any credit entries to my account, I authorize the RSA to make the necessary debit entries to my account. I hereby reserve
the right to revoke or cancel this request, such revocation or cancellation to take effect within 30 days of receipt of written notice by
the RSA.
I authorize my payment to be sent to the financial institution named on the reverse side of this form to be deposited to the
designated account.
Sign Here
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Your Signature ______________________________________________________ Date ___________________
Note: The retiree or beneficiary of a deceased retiree must complete this page. Then take or mail both pages to your financial
institution to verify your information. Your financial institution must complete the second page and agree to the Master Agreement.
continued on next page
RSA DDR
REV 4-16
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