Tennessee Direct Deposit Form 1

Reset Form
Please print or type your name, address, social security number and telephone number. Copy your
social security number from your retirement check or stub. Contact your financial institution for
their correct name and mailing address and enter below.
If you want your retirement payments to go into your checking account, please enclose a voided
check (no deposit slips please). This is to verify the account number and the financial institution’s
routing number. Please complete and sign this form and return it to
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1. Name: ___________________________________________________________________________
Last
First
2. Social Security #: __________________________
Middle Initial
(
)
Area Code/Phone # ___________________
3. Address: _________________________________________________________________________
Street, Rural Route, Box #, Apt. #
_________________________________________________________________________________
City
State
Zip Code
4. Financial Institution Name:_________________________________________________________
5. Financial Institution Mailing Address: _______________________________________________
_________________________________________________________________________________
City
State
Zip Code
(
)
6. Financial Institution Area Code/Phone#: ____________________________________________
7. Type of Account:
H
Checking
H
Savings
If you want your benefit directly deposited into a checking account,
tape a voided, preprinted check in this box. If you want your benefit
directly deposited into a savings account, complete the appropriate
blanks below.
H
Savings
Account # __________________________*Routing # __________________________
* Please contact your financial institution for the correct routing number.
I hereby authorize the Tennessee Consolidated Retirement System to make retirement payments
to my account at the financial institution indicated and I further authorize said financial institution
to accept these credit entries to my account. I understand this agreement may be terminated by me
upon providing written notification to the Retirement System within such time as to afford the
Retirement System and the financial institution a reasonable opportunity to act on it.
SIGN HERE: __________________________________________ _________________________
Signature
Date
TR-0265 (Rev 10/00)
RDA-413