Fillable AUTHORIZATION FOR DIRECT DEPOSIT (Inspirus Credit Union)

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AUTHORIZATION FOR DIRECT DEPOSIT (Inspirus Credit Union)

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WASHINGTON STATE
Department of
Retirement Systems
AUTHORIZATION FOR DIRECT DEPOSIT
PO Box 48380 Olympia, WA 98504-8380 w www.drs.wa.gov
Toll Free: 800.547.6657
w Olympia Area: 360.664.7000 w TTY: 360.586.5450
IMPORTANT – Before completing this form, please read the instructions on the back. Due to federal restrictions, we
cannot transfer funds electronically if the funds will be immediately credited to an account outside of the United States.
Check the retirement system(s) from which you receive benets. If you are receiving more than one retirement benet,
and want each benet deposited in a different account, please complete a separate form for each benet.
Check all that apply:
F Public Employees’ F State Patrol F Law Enforcement Ofcers’ & Fire Fighters’ F Judicial
F Public Safety Employees’ F Teachers’ F School Employees’ (non-teachers)
Section A Payee Information – to be completed by payee
Payee Name (Last, First, Middle) Payee Social Security Number
XXX-XX-
Payee Mailing Address City State ZIP Phone Number
I authorize and request:
• The Department of Retirement Systems (DRS) to transfer the full amount of my monthly benet payment, after
authorized deductions, to the designated nancial institution for deposit.
• The designated nancial institution to provide information to DRS regarding address changes and account
information, to ensure proper and timely processing of deposit transactions.
• The designated nancial institution to refund to DRS any overpayments to my account made subsequent to my death
or payments made in error.
Signature of Payee Date
If different than payee, please list the member’s/retiree’s name and Social Security number:
Member/Retiree Name (Last, First, Middle) Retiree Social Security Number
XXX-XX-
Section B Payee’s Remittance Advice Statement
When the rst payment has been deposited, you will receive a remittance statement at the address provided in Section A.
For future statements, check only one:
F Send a statement when a change is made to my account and at the end of the year.
F Send a statement each time I receive a benet payment.
F Send a statement at the end of the year.
Section C Financial Information – to be completed by Payee (see reverse for details)
Name of Financial Institution Transit/Routing Number
Phone Number Account Type
F Checking F Savings
Account Number to be Credited
Financial Institution Direct Deposit Mailing Address City State ZIP
DRS MS 145 (R 11/12)
*DRSMS145*
Page 1 of 2
Clear Form
Instructions and General Information
IMPORTANT NOTICE
Use this form for all retirement benet payments
from DRS. Direct deposit allows DRS to forward your
payments to the nancial institution you authorize.
The nancial institution may be any bank, savings
and loan association or similar institution, or federal
or state chartered credit union. Members requesting
direct deposit for Plan 3 dened contribution
payments must contact ICMA Retirement Corporation
at 888-711-8773.
PLEASE NOTE: While establishing or making
changes to your direct deposit, your benet may be
mailed to your nancial institution. Please verify with
your nancial institution the actual deposit date.
INSTRUCTIONS
Section A
1. Complete all personal information in the top
section of the form.
2. Print your name where indicated and sign and
date the statement. If the signature can only
be made by mark, it must be witnessed by two
persons who sign the form. If witnesses are
required, they should print the word “Witness”
above their signatures to the right of the mark.
3. Print the name and Social Security number of the
member/retiree, if different from yours.
Section B
If you have any questions, please contact DRS at
360-664-7000 in the Olympia area or toll-free at
800-547-6657.
Section C
Complete all nancial information in the bottom
section of the form. Please check with your
nancial institution for their direct deposit mailing
address.
After completing Section C, forward the form to:
Department of Retirement Systems
P.O. Box 48380
Olympia, Washington 98504-8380
You may want to retain a copy for your personal
records.
Steven M. Bolden
98-442/3251
1234
(360) 555-1234
9876 Maplewood Drive
________________ 20_____
Any City, State 98501
Pay To
$
The Order Of _______________________________________________________________|
_____________________________________________________________________________ DOLLARS
SAMPLE
Security
Features
Details on Back
Your Financial Institution
Your City, USA
ו: 123456789 ו: 000054321987654 װ 1234
For________________________________________
MP
AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY AUTHORIZED SIGNATURE ONLY
Transit/Routing
Account
Check
Number
Number
Number
(do not use)
CANCELLATION INSTRUCTIONS
The routing number must be nine
digits. Ask your nancial institution
for the correct routing number to
enter if:
▪ The routing number on a
deposit slip is different from the
routing number on your checks,
or
▪ Your deposit is to a savings
account that does not allow you
to write checks.
After receipt by DRS, this authorization will remain in effect until canceled by notice to DRS or upon your death.
The nancial institution should also be notied if you cancel this agreement.
Department of Retirement Systems (DRS) requires that you provide your Social Security number for this form.
• DRS will use your Social Security number as a reference number and to ensure that any funds disbursed under
your account are correctly reported to the IRS.
• DRS will not disclose your Social Security number unless required by law.
• Internal Revenue Code Sections 6041(a) and 6109 allow DRS to request your Social Security number.
DRS MS 145 (R 11/12)
Page 2 of 2
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Completed 5 March 2021

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