form 85-8_form85-2.qxd - Maryland State Retirement and Pension

MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
DIRECT DEPOSIT — ELECTRONIC FUNDS TRANSFER SIGN-UP FORM
RETIREMENT USE ONLY
Form 85 (REV. 7/16)
If you need assistance in completing this application, call a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.
SECTION I
To Be Completed by Payee
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.
Please advise the State Retirement Agency (SRA) of change of home
address to receive important information regarding benefits and taxes.
A. SOCIAL SECURITY NUMBER OF PAYEE
—
B.
SECTION II
To Be Completed by Financial Institution
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
—
NAME OF PAYEE (last, first, middle initial)
G. ROUTING NUMBER
CHECK
DIGIT
ADDRESS (street, route, P.O. Box, APO/FPO)
H. PAYEE’S ACCOUNT NUMBER
CITY
STATE
AREA CODE
C.
ZIP CODE + 4
TELEPHONE NUMBER
If you are receiving more than one payment from the SRA
please indicate which payment this EFT applies to:
RETIREE
Important: The payee’s name must appear on
the account.
BENEFICIARY
TYPE OF ACCOUNT
Place “X” in only one box
SRA USE
ONLY
ALL
D.
DATE that electronic fund transfer should begin: __________
E.
PAYEE AUTHORIZATION
By signing my name below, I certify that I am the payee identified above, and hereby authorize SRA to deposit my
allowance into my account at my financial institution. I certify
that I am the account holder of the account indicated on this
form, and the account is not in the name of a trust. I authorize and direct the financial institution, on my behalf, on behalf
of my joint account holder, if any, and my estate to charge
my account for any amounts paid to which I am not entitled
and to return any overpayments to SRA. I also authorize the
release by the bank or financial institution of my current
address, names and current addresses of all persons listed
on the account, including, but not limited to those listed as
“payable on death” or “transfer on death” to SRA.
Signature of Payee
I.
J.
CHECKING ACCOUNT
22
SAVINGS ACCOUNT
32
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the named payee(s) and
the joint account holder(s) and certify that the
payee’s name appears on the account provided in
SECTION H. above. I confirm that all joint account
holders have been listed in SECTION E. left. As a
representative of this financial institution, I certify
that the financial institution is an ACH-participating
Depository Financial Institution. The financial institution agrees to receive and deposit the payment
as identified. The financial institution agrees to
abide by the NACHA Operating Rules and
Guidelines, including the Rules for reclamation of
benefits received after the death of the payee.
Date
NAME AND ADDRESS OF FINANCIAL INSTITUTION:
JOINT ACCOUNT HOLDER CERTIFICATION
By signing my name below, as a party to this account, I
understand that I must immediately advise both the SRA and
the financial institution of the death of the payee. I am personally liable to the SRA for the full amount of all withdrawn
retirement allowance or survivor benefit payments deposited
after the death of the benefit recipient. I authorize the financial institution to provide the SRA with my current address.
Signature of Joint Holder (if any)
Date
Printed Name
Address (street, route, P.O. Box, APO/FPO)
Address (City, state, ZIP code + 4)
F.
Check here only if your entire payment amount is subject
to being transferred to a foreign bank account. See the
following page for more information.
AUTHORIZED REPRESENTATIVE’S SIGNATURE:
PRINT/TYPE REPRESENTATIVE’S NAME AND TITLE:
AREA CODE/TELEPHONE:
DATE:
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
PLEASE READ THIS CAREFULLY
All information on the first page 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. 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.
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 F on the front side of this form.
sra.maryland.gov