Form Revised Dec. 2009 NOTARY PUBLIC OR SIGNATURE OF

RETURN TO: SEAFARERS PENSION PLAN
5201 Auth Way, Camp Springs, MD 20746 • (301) 899-0675 • Fax (301) 702-0668
AUTHORIZATION FOR DIRECT DEPOSIT OF PENSION BENEFITS
Pensioner’s Name: _______________________________________ SS#: _______________________
Home Address: ______________________________________________________________________
City: ___________________________________ State ____________ Zip Code: _________________
New Address? ( ) Yes ( ) Home Phone #: _________________ Cell Phone #: _________________
I authorize the Seafarers Pension Plan to automatically deposit my pension benefits to the following
bank (financial) account:
Account Number: _____________________________ Account Type: Checking (
) Savings (
)
Bank Transit Routing Number (obtain from bank):_______________________________
Bank Name: ______________________________ Bank Phone # ___________________
Bank Address: ____________________________________________________________
Name of Bank Representative (REQUIRED): _______________________________________________
Signature of Bank Representative (REQUIRED): ____________________________________________
A voided check (checking) or deposit slip (savings) with account information and with your name
on it, must be attached to this form.
If funds to which I am not entitled are inadvertently deposited into my account, I (we) authorize the
Seafarers Pension Plan to direct the bank (financial institution) to return said funds. If this account is a
joint account with my spouse or another individual, in the event of my death, the other joint account
holder agrees to return to the Seafarers Pension Plan any funds to which I was not entitled.
REQUIRED SIGNATURES:
PENSIONER (OR POWER OF ATTORNEY OR OTHER COURT APPOINTED
REPRESENTATIVE*): _________________________________DATE: __________________
JOINT ACCOUNT HOLDER:___________________________DATE: ___________________
NOTARY PUBLIC OR SIGNATURE OF PLAN REPRESENTATIVE (REQUIRED):
DUE TO THE PROCESSING SCHEDULE, YOUR REQUEST WILL NOT BECOME EFFECTIVE UNTIL THE
SECOND MONTH FOLLOWING RECEIPT OF THIS REQUEST. ONCE EFFECTIVE IT CAN ONLY BE
CANCELLED BY A WRITTEN, NOTARIZED REQUEST. DIRECT DEPOSIT IS SET UP ONLY FOR
BANKS LOCATED WITHIN THE UNITED STATES AND PUERTO RICO.
THE SIGNATURES ON THIS FORM MUST BE NOTARIZED
* Legal Order must be attached or on file in the Plan Office
Form Revised Dec. 2009