EFT / DIRECT DEPOSIT CANCELLATION REQUEST FORM ( )

EFT / DIRECT DEPOSIT
CANCELLATION REQUEST FORM
TEACHERS’ RETIREMENT SYSTEM
OF THE CITY OF NEW YORK (TRS)
55 Water Street, New York, NY 10041
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided below.
First Name
MI Last Name
Permanent Home Address
City
Social Security Number
Apt. No.
State
Zip Code
TRS Retirement/Beneficiary Number
Daytime Phone Number
(
)
(Check one:
Home
Work)
In the space below, please indicate any recent or upcoming changes to your permanent address (and/or phone number), as well as the
effective date of the changes:
Any address that you enter above will be considered your permanent address, and TRS’ database will be updated accordingly. Therefore,
do not indicate a temporary address above; instead, TRS suggests that you consult the U.S. Postal Service about having your mail
forwarded on a temporary basis.
• Please complete this form if you would like to cancel the Electronic Fund Transfer (EFT) or Direct Deposit of one or both
of the following: a) your monthly retirement allowance under the Qualified Pension Plan (QPP); or b) your monthly annuity
payments from the Tax-Deferred Annuity (TDA) Program.
• Upon TRS’ receipt of this form, your EFT or Direct Deposit will be cancelled. The cancellation should take effect on the first
payroll that occurs 15-45 days after TRS receives this form. You would then receive paper checks each month for your
retirement allowance and/or TDA annuity at the address you designated.
• Please note that TRS no longer permits members to enroll in the Direct Deposit system. Therefore, you may not reinstate
your Direct Deposit after filing this form; however, you may elect EFT for future payments.
• You may reinstate your EFT (or initiate EFT in place of Direct Deposit) after this form takes effect by filing an “EFT
Authorization Form” with TRS. Your EFT should begin 15-45 days after TRS’ receipt of your “EFT Authorization Form,”
provided you completed the form correctly. The “EFT Authorization Form” is available by calling TRS’ Member Services
Center at 1 (888) 8-NYC-TRS and selecting Option 1: the TRS Service Line menu. You may also order forms by using the
“Brochures/Forms” feature on our website at www.trs.nyc.ny.us.
• If you have any questions, please contact TRS at the number above.
BK19 (6/05)
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PART B: Please provide the requested information below.
Name of Financial Institution ____________________________________________________________________________________
Address __________________________________________________________________________________________________
City ______________________________ State ___________________ Zip Code ___________________
Please check the type(s) of payment for which you would like to cancel your EFT/Direct Deposit, and write your initials in the space provided
for each one that you check.
___
QPP retirement allowance
Bank Account Number
___
(Please check one)
Savings Account
Checking Account
(Please check one)
Savings Account
Checking Account
TDA annuity payment
Bank Account Number
PART C: Please read the following statement and sign and date this form.
I elect to cancel the EFT or Direct Deposit of my monthly retirement allowance and/or TDA annuity payments to the financial institution
indicated in Part B. I understand that my EFT or Direct Deposit will be cancelled upon TRS’ receipt of this form and that this cancellation
should take effect on the first payroll that occurs 15-45 days after TRS receives this form. I understand that, once my EFT or Direct Deposit
is cancelled, my retirement allowance and/or TDA annuity payments will be sent to the address I have designated. I also understand that I
may not reinstate Direct Deposit of these payments. However, I may file an “EFT Authorization Form” to resume or initiate EFT at any time
after this form takes effect.
SIGNATURE _________________________________________________________________ DATE (M/D/Y) ______________________
PART D: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.)
State of
)
) s.s.:
County of
)
On the ______________________ day of _____________, _______, before me personally appeared the person known to me to be
_______________________________, the individual who executed the foregoing instrument and acknowledged to me that (s)he executed
the same.
Signature: _______________________________________________________________________________
Official Title: _______________________________________ Expiration Date of Commission: ____________
BK19 (6/05)
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