Form 4-05 R082010 ERBER11 DO NOT FAX FORM PRINT ALL INFORMATION www.lasersonline.org P.O. Box 44213, Baton Rouge, LA 70804-4213 225.922.0600 · Toll-Free 1.800.256.3000 225.922.0612 (hearing impaired) Authorization for Direct Deposit Member's First Name Middle Name Last Name Today's Date Name of Payee Social Security Number Name of Joint Account Holder (if applicable) Social Security Number Payee's Mailing Address Daytime Area Code/Phone Number City Social Security Number Date of Retirement (if applicable) State Evening Area Code/Phone Number Zip Code E-mail Address SECTION 1: ACCOUNT INFORMATION Check at least one of the following options: Name and Address of Financial Institution Monthly Retirement Benefit Type of Account: DROP/IBO Withdrawal Routing Number Depositor Account Number Checking Savings SECTION 2: PAYEE AND JOINT ACCOUNT HOLDER'S SIGNATURE I hereby authorize the Louisiana State Employees' Retirement System (LASERS) to direct the net amount of my monthly benefit payment to my account at the financial institution designated above. This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notifications applicable to these payments. Upon my death, if payments have been deposited to my account that are not due, or if funds are credited to my account in error for any reason, I authorize: 1) LASERS to initiate electronic funds transfer debit transactions to retrieve those payment; and 2) The financial institution (bank or credit union) to release to LASERS the status of my account, my current mailing address, the names and mailing addresses of any joint account holder, and the names and mailing addresses of individuals who have power of attorney relevant to those payments to withdraw funds from my account. If my death should occur prior to the due date of any payment which is made by LASERS in compliance with the Authorization for Direct Deposit, the named financial institution shall refund such payments to LASERS. I certify that I am entitled to the payment identified herein. Any joint signer on the bank account listed below, accepts the responsibility of notifying LASERS of the death of the named Payee, and agrees to accept full responsibility for returning any funds to LASERS which were transmitted by LASERS to the account after the death of the Payee. By signing below, you certify that you have read the provisions of this form, and fully understand the obligations contained herein. Payee's Signature Date Joint Account Holder's Signature Date 4-05 R082010 RETAIN A COPY FOR YOUR RECORDS Reset Form ERBER11 Page 1 of 1 INSTRUCTIONS This form authorizes direct deposits into your account and is to be used only for Louisiana State Employees' Retirement System (LASERS) payment. If you would like your monthly benefit payments to be sent to your financial institution for deposit into your checking or saving account, you must complete this form to authorize the action. The financial institution may be any bank, savings bank, savings and loan association, or similar institution of your choice. Within 60 to 90 days, your payment will begin going to your personal checking or savings account. Deposits will be made by way of electronic funds transfer (EFT) from LASERS account to your account, provided your financial institution is a member of the Automated Clearing House (ACH) system. In the event that your financial institution is not a member of the ACH system, a paper check will be mailed for deposit to your account. If you wish to have the advantage of the "paperless" electronic deposit, you may wish to establish an account with a financial institution that is a member of the ACH system. Please note that after LASERS receives your electronic fund transfer (EFT) request, a pre-notice to your financial institution is needed; therefore you will receive your next monthly benefit in paper check form along with a copy of the pre-notice for your direct deposit as sent to your bank. JOINT ACCOUNT HOLDERS Joint account holders must immediately advise LASERS and the financial institution of the death of the payee. Funds deposited after the death of the payee must be returned to LASERS. After the death of the Payee, Joint Account Holders signing this form agree to be personally liable for any payments made to the financial institution, which are not returned to LASERS. SECTION 1: ACCOUNT INFORMATION 1) Select which payments you would like to go direct deposit; your monthly retirement benefit and/or your DROP/IBO withdrawals (only for LASERS DROP/IBO Accounts). 2) Provide the complete name and address of the financial institution to which payment will be sent. 3) Identify the type of account in which this payment is to be deposited - either Checking or Savings. 4) Enter the Routing Number for your bank (can be found on the bottom left of your check, first set of numbers). 5) Enter your Account Number (can be found on the bottom left of your check, second set of numbers). PAYEE CANCELLATION INSTRUCTIONS This authorization remains in effect until cancelled by written notice from the payee (or the legal representative, in the event of the death of the payee). You may change the designation of your financial institution by completing and submitting a new authorization form. CHECK STUB/ACCOUNT STATEMENT An account statement, similar to a check stub, will be issued only upon establishment of your direct deposit and when a change is made to the gross or net amount payable. You should retain the account statement for future reference. In the event your financial institution is not a member of the ACH System, you will not receive this account statement. A check stub will be attached to the paper check mailed to your financial institution.
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