Direct Deposit Authorization Form
PART A. MEMBER INFORMATION
Member Name
Phone Number
Social Security #
Mailing Address
City/State/ZIP
Email Address
STEP 1
Please fill out your form,
typed or printed in ink,
and remember to sign.
STEP 2
Submit your form...
STEP 3
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3PM,
with a Photo ID
or
...by mailing your form to:
Richmond Retirement System
730 E. Broad Street, Suite 900
Richmond, VA 23219
THANK YOU!
PART B. ACCOUNT INFORMATION - ATTACH A VOIDED CHECK
PART C. CERTIFICATION
I hereby authorize the RRS to deposit payments into my account in the financial institution shown
above. I agree to provide written notification to the RRS of any changes if this information
changes, and I acknowledge that if notification is received after the 15th of the month, it will not
be processed until the following month. I also authorize the RRS to make adjustments to my
account to correct any credit entries made in error.
Signature Date
RRS USE ONLY
This form is for members who would
like to receive electronic payments
from the RRS.
If you are a Power of Attorney or
guardian, please attach a copy of
your Power of Attorney or
guardianship papers.
DIRECTIONS
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 | www.richmondgov.com/retirement
Form revised May 2015
This is a checking account This is a savings account
Bank Name
[Attach a voided check here, not a deposit slip. If you do not have
a voided check, please include a letter from your bank with your
routing number and account number.]
I am a Power of Attorney or guardian, and documentation is attached
I am the member
Forms are processed the 15th
of each month. The month
that this form is processed,
you will receive a paper
check.
The month after you receive a
paper check, you will begin to
receive payments by direct
deposit.
Please remember to ensure
that your address is up-to-date
by submitting a Name and/or
Address Change Form.
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