Louisiana Direct Deposit Form 3

Form 15D (1/13)
Teachers’ Retirement System of Louisiana
8401 United Plaza Blvd, Ste 300 • Baton Rouge, LA 70809-7017
PO Box 94123 • Baton Rouge, LA 70804-9123
Telephone: (225) 925-6446 • Fax: (225) 925-4779
www.trsl.org
10-15D
Form may not
be altered
Do not use for DROP
or ILSB withdrawals
Direct Deposit of Benefits
Direct deposit payment stubs are mailed only when one of the following occurs: (1) establishment of direct deposit, (2) change in net pay, or (3) at the end of the
calendar year.
TRSL offers Member Access, which gives you secure, online access to your retirement account. To register, visit www.trsl.org, and follow the easy instructions.
Section 1 — Benefit recipient information
Name: Last, first, MI, suffix (Jr., III, etc.)
Social Security number
Check here if address change
Telephone
(
Please check one:
)
This is a new direct deposit
setup or a change to a new
bank. (Section 3 required)
Mailing address:
If you are receiving multiple benefit payments, check ONE only
(no selection indicates change will be applied to all accounts):
Change applies to ALL benefit payments
Change applies to RETIREE benefit payments only
Change applies to SURVIVOR/BENEFICIARY
payments only
City, state, zip
This is a change of my
account number with my
same bank. (Bank signature
not required)
Email address
I authorize and request Teachers’ Retirement System of Louisiana (TRSL) to direct the net amount of my monthly benefit payment for crediting to my account at the
financial organization designated below. This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notifications
applicable to these payments. This authorization will remain in effect until canceled by written notice from me to TRSL.
My signature authorizes TRSL to initiate electronic funds transfer debit transactions to retrieve payments sent, but not due, in the event that my death has occurred
or if I become employed in the field of education, public or private, while receiving disability benefits, or if I am no longer a full-time student.
I further authorize the financial organization designated below to release to TRSL, upon request, any and all information regarding my bank account designated
below.
Recipient’s signature (Do not print or type)
Date signed (mm-dd-yyyy)

Section 2 — Information about joint signer (if applicable)
Name of joint signer (if any): Last, first, MI, suffix (Jr., III, etc.)
Social Security number
Relationship to recipient
Telephone
(
Street address only
)
City, state, zip
NOTE: For additional joint signers, complete TRSL’s Addendum to Direct Deposit of Benefits — Nonspousal Joint Signer(s) (Form 15JS).
Section 3 — Financial institution agreement
Name of financial organization
ACH routing number
Address: Street / P.O. Box
Bank account number
Checking
Savings
ATM
City, state, zip
In consideration of Teachers’ Retirement System of Louisiana (TRSL) making payments in accordance with the foregoing request without requiring the personal endorsement of the payee, we hereby agree to repay, subject to disposition required by law and banking guidelines, the amount of any funds on deposit in the recipient’s account at the time of demand that are due TRSL by reason of death of the retiree. We further agree to accept the certification of TRSL as to the date of death
of such payee as sufficient evidence of date of death. In the event that we learn of the payee’s death before TRSL, we agree to notify TRSL of the death and return
any payments received after the death of payee to the extent that funds are available.
Dated at _________________________________________________ this _______________ day of ________________________________________________ , _________________.
Signature of financial officer (Do not print or type)

Name and title of financial officer (Print or type)
Telephone
(
Toll-free number
)
Return original or fax to Teachers’ Retirement System of Louisiana