Form 6186 - Authorization For Direct Deposit printable pdf download

Form 6186 - Authorization For Direct Deposit

SACRAMENTO COUNTY EMPLOYEES’ RETIREMENT SYSTEM

980 9

STREET, SUITE 1900

SACRAMENTO, CA 95814

PHONE: (916) 874-9119

FAX:

(916) 874-6060

WEB:

AUTHORIZATION FOR DIRECT DEPOSIT

To sign up for direct deposit of your retirement warrant, follow these procedures:

Fill in the information in Section 1.

Take this form to your financial institution and ask them to complete Section 2. Accuracy is extremely

important, since your warrant will be deposited into the account number provided.

Return the completed original form to: SCERS, Pension Payroll, 980 9

Street, Suite 1900, Sacramento, CA

95814 or Fax to (916) 874-6060.

If you have any questions, please call our office at (916) 874-9119

SECTION 1 (TO BE COMPLETED BY RETIREE/MEMBER)

Name (please print)

Social Security Number

In signing this form, I authorize the Chief Executive Officer (CEO) of SCERS or his designee to send 100%

of my net pay to the financial institution and account designated in Section 2 below.

I authorize amounts transmitted after my date of death or transmitted in error to be debited to my account.

This authority is to remain in full force and effect until the CEO has received written notification from me of

its termination and is afforded a reasonable opportunity to act on it.

___________________________________________ __________________ ____________________________

Signature

Date

Telephone No.

SECTION 2 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

Institution Name, Branch, and Phone

Type of Depositor Account (CHECK ONLY ONE)

Checking

Savings

Routing Number

Account Number

I confirm the identity of the above-named payee and the account number. As a representative of the

above-named financial institution, I certify that the financial institution agrees to receive and deposit

receive and deposit the payment identified above.

PRINT Representative’s Name

Signature and Date

Form 6186 (Revised August 2012)

Form 6186 - Authorization For Direct Deposit