Information About Your Account
Section 1
Information About You
A separate form must You will receive a confirmation letter with the effective date once CalPERS has processed this completed form. In order
be completed for each type to receive important information about benefits, payees should keep CalPERS informed of any address changes.
of retirement benefit to be
sent by direct deposit.
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
( )
Address Daytime Phone
City State ZIP Code
Section 2
If you are authorizing your
c
Checking
c
Savings
c
Individual
c
Joint (If so, Complete Section 3)
c
Trust Account *
payment to your savings
account or do not have
Routing Number (nine digits) Account Number
pre-printed, personalized
checks, please have
Please use tape to attach your voided, pre-printed personalized check. (Do not staple or paper clip. No deposit slips.)
your financial institution
complete this section.
( )
Name of Financial Institution Branch Phone Number
* Trust Accounts
You also need to complete
Address
and submit a Payment of
Monthly Allowance to a
City State ZIP Code
Trust (Annuitant) form or
You confirm the identity of the above-named payee and the account number. As a representative of the above named
a Certification of Trust
financial institution, you certify the financial institution agrees to receive and deposit the payment identified above.
Payment of Continuing
Monthly Allowance
(Successor Trustee)
Signature of Representative Print Representative’s Name Date (mm/dd/yyyy)
form available at
www.calpers.ca.gov.
Section 3
Information About Joint Account Holder (If applicable)
Name Social Security Number or CalPERS ID
( )
Address Daytime Phone
City State ZIP Code
Direct Deposit Authorization
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
PERS-BSD-1199P (5/17) Page 1 of 2
Put your name and Social
Security number or CalPERS ID
at the top of every page
Your Name Social Security Number or CalPERS ID
Section 4
Certification
Signature required. I certify I am entitled to the payment identified above. In signing this form, I authorize my payment to be sent to
my financial institution and deposited to my designated account. I understand CalPERS does not accept a prepaid
debit card as a payment option. I authorize amounts transferred after my death or transmitted in error to be debited
**To comply with NACHA
from my account. Additionally, I certify that the funds received are not deposited to an account that is subject to
regulations regarding
being transferred to a foreign financial institution.**
International ACH
Transactions (IAT), CalPERS
will not accept requests for
Signature of Payee Date (mm/dd/yyyy)
electronic fund transfers (EFT)
in association with financial
You can view and print your benefit statement, which shows your total deposit amount, including any reimbursements
institutions outside of the
or authorized deductions, at my.calpers.ca.gov. If you have not created your account, you must follow the steps to
territorial jurisdiction of the
complete the registration process.
United States. (The territorial
jurisdiction of the United
States includes all 50 states,
U.S. territories, U.S. military
bases, and U.S. embassies
in foreign countries.) If your
entire benefit allowance will
be received by a financial
institution outside the
territorial jurisdiction of the
U.S., you will be issued a
paper check in lieu of the EFT.
Mail to: CalPERS Benefit Services Division P.O. Box 942716, Sacramento, California 94229-2716
PERS-BSD-1199P (5/17) Page 2 of 2
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections
20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
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