Electronic Funds Transfer Direct Deposit Enrollment Application Form
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1
2Electronic Funds Transfer
Office of the New York State Comptroller
Thomas P. DiNapoli
Direct Deposit Enrollment Application
New York State and Local Retirement System
RS 6370L-3 (Internet Version) (Rev. 7/09)
Employees’ Retirement System
Police and Fire Retirement System
Date stamp:
110 State Street, Albany, New York 12244-0001
Phone: 1-866-805-0990 or 518-474-7736 Fax: 518-402-4433
Email: nyslrsinfo@osc.state.ny.us Web:
SECTION 1. TO BE REVIEWED AND CORRECTED BY PENSIONER
Name: _______________________________________
Soc. Sec. #: __________________________ Retirement #: ____________________
Address:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Home Telephone: (______) ______________________ (Please Provide)
Registration #: ________________________________________
SECTION 2. TO BE COMPLETED BY PENSIONER
I hereby request all future benefits which become payable to me from the New York State and Local Retirement System (NYSLRS) be transferred to
my account via Electronic Funds Transfer (EFT) Direct Deposit to:
Name of Financial Institution: ____________________________________________________________________________________________
Account Type:
o
Checking (attach voided check to Section 3, or have Section 3 completed by your financial institution)
If your checks do not have your name imprinted on them, Section 3 must be completed by the financial institution.
o
Savings (Section 3 must be completed by financial institution.)
NYSLRS is authorized to continue making such benefit payments to said financial institution or any of its successors until NYSLRS receives written
notice from me to the contrary. I agree the NYSLRS shall have no liability or responsibility for loss occasioned by erroneous information supplied by
myself, my duly authorized representative, or the financial institution.
I expressly acknowledge and understand any payments made pursuant to this request will be strictly an accommodation made to me by NYSLRS.
NYSLRS reserves the right to discontinue or decline to honor this EFT request without prior notice.
I hereby authorize and direct the financial institution, on my behalf, my joint account holder, if any, and my estate to charge my account for amounts
paid to which I was not entitled. I also agree, on behalf of myself, my joint account holder, if any, and my estate, that such amounts will be returned
to the NYSLRS.
By making this request, I hereby represent the account identified herein (and as may later be modified) is not a trust held for the benefit of another.
Signature: ______________________________________________________________________________
Date: ________________________
Signature of Joint Holder (If any): __________________________________________________________
Date: ________________________
SECTION 3. TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION IF DIRECTING FUNDS INTO A SAVINGS ACCOUNT
OR IF A VOIDED CHECK IS NOT ATTACHED. THE ABOVE PENSIONER’S NAME MUST APPEAR ON THE ACCOUNT.
(Attach a preprinted voided check with your name imprinted on check here)
o
o
Account Type:
Savings
Checking
Transit/ABA Number (ACH Format)
Depositor’s Account Number (EFT Format)
Name of Financial Institution: ____________________________________________________________________________________________
Address:
Telephone: ( ______ _) ____________________________
City: ________________________________________________________ State: _______________________ Zip Code: ___________ - ______
I, as representative of the above named financial institution, agree to abide by the NACHA Rules and Regulations. Amounts paid to the account
holder to which he/she is not entitled will be returned to NYSLRS. Liability shall be limited as prescribed in Section 4.7 of the NACHA Rules and
Regulations.
Bank Officer Signature: _____________________________________________________ Title: _______________________________________
Bank Officer (please print): __________________________________________________
PLEASE SEE BACK FOR INSTRUCTIONS
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