Fillable Direct Deposit Request Form

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Direct Deposit Request Form

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DIRECT DEPOSIT REQUEST
For Pension Risk Transfer Annuities
11/18 [PRT Direct Deposit] Page 1 of 1
CONTACT INFORMATION
Pacific Life
P.O. Box 84307
Lincoln, NE 68501-4307
Toll Free: (800) 800-9534
Fax: (402) 479-0102
Web Site: www.PacificLife.com
All Overnight Deliveries:
Pacific Life
777 Research Drive, Suite 219
Lincoln, NE 68521
Use this form to establish or change an existing direct deposit program.
( )
Address City, State, ZIP
2
BANK/DEPOSITORY INFORMATION I, (print name) am/will be receiving
payments. As a payee, I request that the payment be electronically deposited into my (Select One):
□
Checking Account
□
Savings Account
Please attach a current voided check or savings deposit slip in the space provided below for verification of account information.
Starter checks are not acceptable to establish direct deposit.
Tape a copy of a void check or deposit slip here.
I hereby authorize Pacific Life to initiate deposits (credits) and debit my account for any erroneously credited to and from the financial institution indicated above.
The financial institution is authorized to credit and/or debit to my account. This authority is to remain in full force and effect until Pacific Life has received written
notification from me of its termination in such time and in such manner as to afford Pacific Life and Bank/Depository a reasonable opportunity to act on it. These
instructions will take the place of any previous or existing instructions on file.
___________________________________________________________________ _______________________________________
Signature month / day / year
SIGN
HERE
3
ACKNOWLEDGEMENT AND SIGNATURE(S) Please read and sign below:
Bank Name
Telephone Number
( )
Address City, State,
Account Number
ABA/Routing Number
GENERAL INFORMATION Claimant/Payee Name (First, Middle, Last)
1
Telephone Number
Policy and Certificate Number (if known)
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Direct Deposit Request Form

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Completed 18 July 2020

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