Form # 315
Revised 8/2018
1400 West Third, Little Rock, AR 72201
Phone (501) 682-1517 or (800) 666-2877
Fax (501) 682-2359
Website -
Direct Deposit Authorization Form
Payee Type: Member Survivor Beneficiary QDRO Recipient ▪ Member's SSN: ________
Payee Information
Payee's Name________________________________________________SSN________________________________
Mailing Address___________________________________________________________________________________
City _______________________________ State ______________________________ Zip ____________________
Telephone Number (____) ______________________ E-mail Address ______________________________________
I hereby authorize the Arkansas Teacher Retirement System (ATRS) to deposit to the account indicated below the net
amount I am due each month as if a check had been delivered to me for that amount. Should an overpayment or
underpayment be made, ATRS is authorized to initiate any debits or credits necessary to correct the account.
Checking Account Savings Account Reloadable Pay Card
Checking or Savings Account - Please attach a voided check where indicated, or complete the
Account Information section below.
Reloadable Pay Card - complete the Account Information section below.
Note: To the extent you are using an account other than a standard bank account, the member/beneficiary assumes responsibility for
the loss of any funds.
Account Information (or attach voided check below)
By providing my account information below in lieu of attaching a voided check I understand
that ATRS shall have no liability or responsibility for loss due to erroneous information supplied
by me or my duly authorized representative.
Financial Institution Name _______________________________________________________
City ______________________________ State ___________________ Zip _______________
Routing Number (ACH) _________________________________________________________
Account Number ______________________________________________________________
Attach Voided Check Here
This authority is to remain in full effect until ATRS has received written notification from me of its termination. I
understand that by having my benefits deposited in this manner, I will receive a deduction statement in July and
December and that there will be no charge for this service.
Payee's Signature ____________________________________ Date _________________
If you are a power of attorney, conservator, or guardian over the payee, please include a copy of the power of
attorney, or certified copy of the order. If you are a trustee, please include a copy of the trust agreement.