Direct Deposit Authorization
NOTE: Please complete the Certication of Trust and Authorization form located
on our website for direct deposit of payments to a Trust Account.
PAYEE'S PERSONAL DATA
Please type or use only black ink and do not highlight. Mail or fax completed form to TMRS.
Name (first, middle, last) Social Security Number
Mailing Address Date of Birth (MM/DD/YYYY)
City State Zip Daytime Phone Number
E-mail Address TMRS Identification Number (not required)
FINANCIAL INSTITUTION DATA
Financial Institution Name Financial Institution Phone Number
To ensure accuracy, please tape a voided check here (no deposit slips).
Routing Number (first nine digits) Payee Account Number Individual's Name(s) on Financial Account*
Type of Account: q Checking q Savings
PAYEE'S AUTHORIZATION
I authorize the Texas Municipal Retirement System (TMRS) to deposit my TMRS retirement benefit electronically to the financial institution and the account indicated above.
I authorize TMRS and the Financial Institution to correct any credit entries made in error. I hereby authorize the financial institution named above to disclose to TMRS at any
time my address and contact information, and to disclose the names and address of all joint owners, signatories, beneficiaries or other persons associated with the above
referenced account if I pass away. A photocopy of this signed form shall be sufficient authorization for such disclosure. Making false or misleading statements on any form
submitted to TMRS is a violation of State law and has criminal and potential civil liability.
Payee's Signature
Date (MM/DD/YYYY)
TMRS • P.O. Box 149153 Austin, Texas 78714-9153 • 800.924.8677 • 512.476.7577 • FAX 512.476.5576 • www.tmrs.com
*TMRS080E*
TMRS - 080E • Revised 9-2015
Important
Information
About Direct Deposit
Account Changes
If you change your account
or account number, you
must file another direct
deposit authorization.
Fund Availability
Generally, your money
will be deposited to your
account and available by
the last business day of
the month.
* Note:
If you are not an account holder on this account, we cannot process
your request for direct deposit.
Please check one.
JOHN DOE
123 ANYPLACE TRL.
SOMEWHERE, TX
113000029 004499123456 1234
For
Bank of Somewhere
Date
Pay to the
order of
$
1234
Dollars
SAMPLE