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.
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