Application For A Disability Allowance Page 11
Download a blank fillable Application For A Disability Allowance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For A Disability Allowance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12CT TEACHERS’ RETIREMENT BOARD
765 ASYLUM AVENUE HARTFORD, CT 06105-2822
“An Affirmative Action/Equal Opportunity Employer”
Toll-Free 1-800-504-1102
(860) 241-8400
Fax (860) 525-6018
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION
I authorize the CTRB to initiate the electronic deposit of my monthly recurring benefits into my personal account at a
financial institution that is a participating member of the National Clearing House Association (NACHA). I understand
that this bank account must be a personal bank account and not a business, trust or other form of account.
I also understand that by electing an electronic deposit of my benefit I will get a statement from the CTRB only when my
monthly net benefit changes, rather than a monthly statement. The statement will denote the change including but not
limited to changes in tax deductions or health insurance premiums thereby enabling me to account for all benefit activity.
This authorization applies to all monthly payments by the CTRB including retirement benefits, survivorship benefits, and
disability allowances. In the event of my death, I authorize my estate to reimburse CTRB for any amounts which I was
not entitled to receive and which were deposited following my death.
MUST BE A PERSONAL BANK ACCOUNT OF THE MONTHLY BENEFIT RECIPIENT OR THE MONTHLY
BENEFIT RECIPIENT’S LEGAL DESIGNEE (CONSERVATOR OR POA); MAY NOT BE A BUSINESS, TRUST,
OR OTHER FORM OF ACCOUNT):
PLEASE CHECK THIS BOX IF THIS IS A NEW ADDRESS
Monthly Benefit Recipient’s Name
Social Security Number
Street Address
Email Address
City, State, Zip
Home Phone
Monthly Benefit Recipient’s Signature
Date Signed
ATTACH A VOIDED CHECK WHICH INCLUDES THE BANK NAME, ACCOUNT HOLDERS’ NAME, ROUTING NUMBER,
AND ACCOUNT NUMBER OR HAVE THE FINANCIAL INSTITUTION COMPLETE THE FOLLOWING:
Financial Institution must be a participating member of the National Automated Clearing House Association (NACHA).
Routing Transit Number
Bank Account Number
(Not to exceed 9 digits)
(Not to exceed 17 digits)
must be or include Monthly Benefit Recipient’s name
Account Holder (
)
Bank Account Type (select one):
Name of Financial Institution
Checking
Street Address
Savings
City, State, Zip
Phone
Signature of Bank Representative
Date Signed
Check this box and sign under Monthly Benefit Recipient’s signature above to decline EFT; CTRB will mail a paper check
to the address on our records.
CTRB does not acknowledge the receipt of individual forms. CTRB must receive the completed form by the 1st of the month in
order for the EFT to be effective at the end of the month. (Benefits for the month are issued on the last business day of that
month.)
EFT (Rev. 07/28/14)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Hsmv 83007 - Application For A Disabled, Disabled Veteran Or Motorcycle International Wheelchair Symbol License Plate
Legal
Application For A Central Visual Acuity Disability Permit Form - Wyoming Game And Fish Department
Legal
Related Categories
Parent category: Legal