Authorization for Direct Deposit Form 4-05

Form 4-05
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
Fax 225.935.2856 · 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
Social Security Number
Date of Retirement (if applicable)
Evening Area Code/Phone Number
Zip Code
Email Address
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
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
Joint Account Holder's Signature
4-05 R062015
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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 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.
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
5) Enter your Account Number (can be found on the bottom left of your check, second set of numbers).
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.
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.