Maryland Direct Deposit Form 1

MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
DIRECT DEPOSIT — ELECTRONIC FUNDS TRANSFER SIGN-UP FORM
If you need assistance in completing this application, telephone a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.
SECTION I
To Be Completed by Payee
SECTION II
To Be Completed by Financial Institution
Directions for Payee:
1) Please read the instructions printed on the following page.
2) Complete SECTION I.
3) Provide this form to your financial institution so that they may
complete Section II.
* Advise the Maryland State Retirement Agency (SRA) of
change of home address to receive important information
regarding benefits and taxes.
Directions for Financial Institution:
1) Verify information in SECTION I.
2) Complete SECTION II.
3) Send completed form to: Maryland State Retirement Agency
ATTN: EFT Department
120 East Baltimore Street
Baltimore, MD 21202-6700
or fax to: EFT Department at 410-468-1700
A. SOCIAL SECURITY NUMBER OF PAYEE
H.
NAME AND ADDRESS OF FINANCIAL INSTITUTION
I.
ROUTING NUMBER
—
—
B. NAME OF PAYEE (last, first, middle initial)
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY
STATE
CHECK
DIGIT
ZIP CODE + 4
DEPOSITOR ACCOUNT TITLE
AREA CODE
TELEPHONE NUMBER
J.
PAYEE’S ACCOUNT NUMBER
K.
TYPE OF ACCOUNT
Place “X” in only one box
C. If you are receiving more than one payment from the
SRA please indicate which payment this EFT applies to:
RETIREE
BENEFICIARY
ALL
SRA USE
ONLY
D. DATE THAT ELECTRONIC FUND TRANSFER
SHOULD BEGIN.
E.
PAYEE CERTIFICATION
I certify that I am the payee identified above, and that I have
read and understood the instructions on this form. In signing
this form, I authorize my pension payment to be sent to the
named financial institution to be deposited to the designated
account.
SIGNATURE OF PAYEE:
L.
CHECKING ACCOUNT
22
SAVINGS ACCOUNT
32
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the named payee(s) and the account
number and title. As representative of this financial institution,
I certify that the financial institution agrees to receive and
deposit the payment as identified.
DATE:
PRINT OR TYPE REPRESENTATIVE’S NAME:
JOINT ACCOUNT HOLDERS’ CERTIFICATION
F. I certify that I have read and understood the instructions on
SIGNATURE OF REPRESENTATIVE:
this form including the SPECIAL NOTICE TO JOINT
ACCOUNT HOLDERS.
SIGNATURE OF JOINT ACCOUNT HOLDER:
DATE:
AREA CODE/TELEPHONE:
G.
Check here only if your entire payment amount is subject
to being transferred to a foreign bank account. See
reverse side for more information.
FORM 85 (REV. 6/10)
DATE:
www.sra.state.md.us
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
PLEASE READ THIS CAREFULLY
All information on the reverse side of this form, including the individual Social Security
number, is required. The information is confidential and will be used only to process payment data
from the Maryland State Retirement Agency to the financial institution and its agent. Failure to
provide the requested information may prevent the receipt of payments through the Electronic
Funds Transfer Program.
Special Notice to Joint Account Holders
Joint account holders should immediately advise both the Maryland State Retirement Agency
and the financial institution of the death of the Maryland State Retirement Agency payee. Funds
deposited after the date of death are to be returned to the Maryland State Retirement Agency. The
Maryland State Retirement Agency will then make a determination regarding survivor rights, and
process survivor benefit payments, if any.
Cancellation
The agreement presented by this authorization remains in effect until cancelled by the
recipient by notice to the Maryland State Retirement Agency or by the death or legal incapacity of
the recipient. Upon cancellation by the recipient, that recipient should notify the receiving financial
institution that he/she is doing so.
The agreement represented by this authorization may be cancelled by the financial institution
by providing the recipient a written notice 30 days in advance of the cancellation date. The
recipient must immediately advise the Maryland State Retirement Agency if the authorization is
cancelled by the financial institution. The financial institution cannot cancel the authorization by
advice to the Maryland State Retirement Agency.
Changing Receiving Financial Institutions
The payee’s Electronic Fund Transfer arrangement will continue until the Maryland State
Retirement Agency is notified by the payee that the payee wishes to change the financial
institution receiving the Electronic Funds Transfer. To effect this change, the payee will complete
a new FORM 85 form. The payee should maintain accounts at both financial institutions
until the transition is complete, i.e. after the new financial institution receives the payee’s
Electronic Funds Transfer payment.
International Automated Clearing House Transaction Rules
Electronic payments to your designated account must comply with the provisions of U.S. law,
as well as the requirements of the Office of Foreign Assets Control.
If you receive your monthly retirement benefit via direct deposit at a U.S. bank and then
you have the entire benefit amount forwarded to a foreign bank (a bank located in a country
outside the United States), please check the box labeled G on the front side of this form.