©2014 Pension Dynamics Company LLC. All rights reserved.
DIRECT DEPOSIT AUTHORIZATION
Company/Plan Name:
Name
SECTION 1. EMPLOYEE INFORMATION
Social Security Number
Evening Phone NumberEmail Address (Required) Daytime Phone Number
SECTION 2. TYPE (Please select one)
Initiate Direct Deposit Change Account Cancel Direct Deposit
SECTION 3. BANK INFORMATION Please print legibly
Savings
Checking
Provide account information below.
Provide account information below and attach a copy of a voided check.
Bank Routing Number Nine Digits, starts with 0, 1, 2, 3, or 4. Bank Name
Checking or Savings Account Number Checking or Savings Account Owner Name
I acknowledge the following:
If I do not provide a copy of a voided check Pension Dynamics is not responsible for failed bank transmittal due to incorrect banking information.
Deposit slips cannot be accepted as the routing numbers are often different on these slips.
My financial institution can receive transactions via electronic transfer and the bank information provided can serve this purpose.
I authorize Pension Dynamics Company LLC to initiate electronic credit entries and, if necessary, debit entries to reverse erroneous credits to the
above account, and to allow the financial institution indicated above to credit and / or debit the same to such account.
Direct deposit of my reimbursement accounts shall commence within 2 (two) weeks of receipt of this form. This direct deposit will be for all
reimbursement accounts that I have established with Pension Dynamics.
My direct deposit may be terminated by any of the following: an online or written cancellation request submitted by me (when allowed by my
employer), a failed bank transmittal due to incorrect bank information, or cancellation of direct deposit by my employer.
I must notify Pension Dynamics immediately if I make any changes to my banking situation. Not doing so can delay my payment greatly.
I will not assume payment has been made to my bank account at any time. I am solely responsible for checking with my bank as to the deposit
amount and date of direct deposits made. I am also responsible for any fees my bank may charge for direct deposits.
I understand the information on this form and authorize Pension Dynamics Company LLC to complete my request as indicated:
SECTION 4. EMPLOYEE AUTHORIZATION
Date
Employee Signature
Submit via - Email: benefits@pensiondynamics.com or Fax: (844) 859-7309
