California Direct Deposit Form 3

DIRECT DEPOSIT FOR MONTHLY BENEFIT
Send completed form to:
UC Human Resources
P.O. Box 24570
Oakland, CA 94623-1570
UCRS 160 (R8/12) University of California Human Resources
Use this form to begin, change or cancel the electronic deposit of your monthly benefit. There may be a waiting period before your direct deposit
change takes effect, determined by monthly processing deadlines.
1. PERSONAL INFORMATION (Please complete entire section)
NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
DAYTIME PHONE
(
MAILING ADDRESS (Number, Street)
CHANGE MY ADDRESS
(City, State, ZIP, Country)
STATUS (Check all that apply)
YES
)
BENEFIT PAYMENT TYPE (Check one)
UCRP
NO
UC PERS VERIP
UC 415(m)
OTHER (NON-MEMBER)
RETIRED / DISABLED
SURVIVOR / CONTINGENT ANNUITANT
2. ACTION AND ACCOUNT TYPE
Action (check one):
New enrollment
Cancel direct deposit
Change my account. My current account will remain open until my new account is in effect.
Change my account. I have closed my account. Send my future checks to my mailing address until my new
account is in effect.
Account type for new enrollment or direct deposit change (check one):
Savings account (Complete Sections 4 and 5)
Trust account (Must be grantor-type trust; tax I.D. number must be payee’s
SSN) check one box below:
Checking account (Complete Sections 3 or 4 and 5)
Trust savings account (Complete Sections 4 and 5)
Trust checking account (Complete Sections 3 or 4 and 5)
3. FOR COMPLETION BY PAYEE (You must attach a voided printed check. Do not attach a deposit slip.)
NAME OF FINANCIAL INSTITUTION
ACCOUNT NUMBER
BRANCH NAME AND ADDRESS
BRANCH TELEPHONE NUMBER
(
)
(City, State, ZIP)
4. FOR COMPLETION BY FINANCIAL INSTITUTION
NAME OF FINANCIAL INSTITUTION
ACCOUNT NUMBER (Show the number exactly as required for direct deposit.)
(
BRANCH NAME AND A\DDRESS
)
BRANCH TELEPHONE NUMBER
BANK TRANSIT ROUTING NUMBER
I confirm the identity of the above-named payee and the account number. As a representative of the above-named financial institution, I certify
that the financial institution agrees to receive and deposit the payment identified above.
SIGNATURE OF REPRESENTATIVE
PRINT / TYPE REPRESENTATIVE’S NAME
5. CERTIFICATION AND AUTHORIZATION (Signature(s) required)
JOINT ACCOUNT HOLDER’S CERTIFICATION
I certify that I am entitled to the payment identified above, and that I have read and understand the information and instructions on this form. In signing this form, I authorize my
payments to be sent to my financial institution and deposited to the account I have designated. If the account designated is a trust account, I also certify that the account tax I.D.
number is my Social Security number. I authorize UC Retirement Administration to debit my
account for any amounts transmitted in error or after my death. If the funds have been
withdrawn following my date of death, I authorize my financial institution to release to UC
the name and address of the person(s) responsible for withdrawing the funds. I understand
that if deposits are being made to a joint account, the other account holder must sign
the “Joint Account Holder’s Certification” section (at right). I further agree that if the
account specified above becomes a joint account (or if the joint account holder changes), I
must complete a new form. I understand that this authorization will remain in effect until I
cancel it by submitting a new form.
SIGNATURE OF PAYEE
DATE
I certify that I have read this form. If the payee
named at left dies, I agree to refund to the
University any payments deposited in our
account that he or she was not entitled to receive.
(Please notify UCRS of the death of the UCRS
payee.)
DATE
SIGNATURE OF JOINT ACCOUNT HOLDER
DATE
FOR UC HUMAN RESOURCES USE ONLY
TRANSIT ROUTING NUMBER ACCOUNT NUMBER INPUT BY DATE TRANSACTION TYPE
AUDITED BY SEE REVERSE FOR PRIVACY NOTIFICATIONS
DATE
MEMBER–PHOTOCOPY THIS FORM FOR YOUR RECORDS.
PRIVACY NOTIFICATIONS
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to
individuals who are asked to supply information about themselves.
The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity, and/or for
benefits administration, and/or for federal and state income tax reporting. University policy and state and federal statutes authorize the
maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent
completion of the action for which the form is being filled out. Information furnished on this form may be transmitted to the federal and state
governments when required by law.
Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements.
Information on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel
Offices.
The official responsible for maintaining the information contained on this form is the Vice President—University of California Human
Resources, 1111 Franklin Street, Oakland, CA 94607-5200.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security number is mandatory. The
University’s record keeping system was established prior to January 1, 1975 under the authority of The Regents of the University of
California under Article IX, Section 9 of the California Constitution. The principal uses of your Social Security number shall be for state tax
and federal income tax (under Internal Revenue Code sections 6011.6051 and 6059) reporting, and/or for benefits administration, and/or to
verify your identity.