New Jersey Direct Deposit Form 3

FC-0430-0711
STATE OF NEW JERSEY - DIVISION OF PENSIONS AND BENEFITS
AUTHORIZATION FOR DIRECT DEPOSIT OF BENEFIT PAYMENT
INSTRUCTIONS:
A: Read the terms and conditions listed below.
MAIL TO:
B: Enter your name, mailing address, retirement number (for retirement payment and surDirect Deposit
vivor benefit), Social Security number, and home telephone number.
Division of Pensions
C Mark the appropriate payment and account type boxes, and print the financial institution's
account number, routing number, and name and address where indicated. Be sure to
and Benefits
double-check your account and 9-digit routing numbers before submitting this form —
PO Box 295
inaccurate information will delay processing of this application or your payment.
Trenton, NJ 08625–0295
D: You and all other parties to this account must sign the form.
E: Attach a VOIDED check if using a checking account and return the completed form to the
Division of Pensions and Benefits.
___________________________________________________________________________________________________________
RECIPIENT INFORMATION — Please Print Legibly
Fund: PERS TPAF PFRS SPRS JRS
Your Name: _____________________________________
Retirement No: __________________________________
(For Retirement Payment and Survivor Benefit Only)
Your Address: ___________________________________
Social Security No: ______________________________
______________________________________________
Home Phone No: ________________________________
TYPE OF PAYMENT:
⌧ RETIREMENT PAYMENT/SURVIVOR BENEFIT
_____________________________________________
_____________________________________________
Your Account Number
Name of Financial Institution
_____________________________________________
Street of Financial Institution
TYPE OF ACCOUNT: CHECKING SAVINGS
_____________________________________________
_____________________________________________
City, State, Zip of Financial Institution
Financial Institution’s 9-digit Routing Number
_____________________________________________
Your Signature and Date
_____________________________________________
_____________________________________________
Signature(s) of Other Persons On Account and Date(s)
Please read the terms and conditions below and
ATTACH A VOIDED CHECK IF AUTHORIZING A CHECKING ACCOUNT
(used to verify your financial institution's routing and account number)
TERMS AND CONDITIONS
Benefit Recipient
I authorize the New Jersey Division of Pensions and Benefits and the financial institution indicated to directly deposit my net retirement
allowance or survivor benefit each month to the account specified. Direct deposit under this authorization is full satisfaction and discharge of the
amount then due and payable under the retirement system or benefit program. I understand that the provisions of the statutes governing the pension funds prohibit the deposit of retirement payments to a trust fund. I understand that any retirement allowance or survivor benefit forwarded
to the financial institution with a due date after my death will be refunded to the appropriate retirement system. I agree that the financial institution shall have the right of offset for such a refund.
I further understand that this agreement may be changed by me upon written notification to the Division of Pensions and Benefits. The
change will be processed for the pay period following receipt of the notice by the Division. I understand that a change in the title of this account
which alters the interest of any party terminates this authorization, a notification must then be submitted. I understand that it is my responsibility
to inform the Division of Pensions and Benefits of address changes immediately. I authorize the financial institution to provide the Division of
Pensions and Benefits with my home address.
Other Parties to the Account
As a party to this account, I understand that I am personally liable, both individually and as a member of the group of parties to this account,
for the full amount of all retirement allowances or survivor benefit payments with due dates after the death of the benefit recipient withdrawn from
the account. This liability is to the retirement system or benefit program. If I am entitled to any benefit from the retirement system or benefit program as a beneficiary of the benefit recipient, the amount of my liability may be deducted from the amount payable to me. I agree that the financial institution shall have the right of offset for such a refund and I authorize the financial institution to provide the Division of Pensions and
Benefits with my home address.