Form F399 - Affidavit Concerning Lost Check (Page 4 of 4) in pdf

Form F399 - Affidavit Concerning Lost Check Page 4

NYCERS USE ONLY

F399

Mail completed form to:

30-30 47th Avenue, 10th Fl

Long Island City, NY 11101

Member Number

Last 4 Digits of SSN

Pension Number

Read and complete the information in this section ONLY if you checked a box on page 1 to indicate that the lost check is for a Tier 3,

Tier 4 or Tier 6 Loan, Refund (all tiers), Lump-Sum Survivor Benefit (Death in Service), or Lump-Sum Pensioner Survivor Benefit

and you choose to have your replacement check deposited directly into your account by Electronic Fund Transfer (EFT). If you do not

complete this section, your replacement check will be mailed to the address on file.

• Make sure you have filled out the first two pages of this form, Affidavit Concerning Lost Check.

• Attach one of your preprinted personal checks or preprinted savings deposit slips in the space provided below.

If your bank no longer provides personal checks or preprinted savings deposit slips, attach a copy of the top portion of your

Checking or Savings Account Bank Statement.

• If submitting a preprinted check or deposit slip write VOID (in large letters) across the face, as indicated in the sample below.

• Do NOT sign the check that you are attaching to this page.

• Write in your Bank Name, Account Number, the Bank Routing Number and select which account you

want your funds directly deposited into under “Banking Information.”

• Mail or bring this completed form (including complete Affidavit Concerning Lost Check) to NYCERS.

NOTE: Lost rollover checks can only be replaced by a paper check, not by direct deposit.

BANKING INFORMATION

Checking

Savings

Deposit to my

Bank Name

Account #

Bank Routing Number

R11/17

Page 4 of 4

Form F399 - Affidavit Concerning Lost Check Page 4