Direct Deposit System Form
General Employees’ Retirement Fund, 306 E. Jackson Street, 7E, Tampa, FL 33602 • (813) 274-7850 • Fax: (813) 274-7289
Phone Number:
PART C. ACCOUNT INFORMATION - ATTACH A VOIDED
CHECK
Bank Name:
Checking
Savings
[Attach a voided check here]
we cannot accept a deposit slip or starter checks
If you do not have a voided check, please include a
letter from your bank with your printed name,
address, routing number and account number on their
letterhead.
PART D. CERTIFICATION
I hereby authorize the General Employees’ Retirement Fund to deposit payments into my account
in the financial institution(s) shown above. I agree to provide written notification to the Fund if
this
information changes. I acknowledge that I understand, if notification is received after processing
for the month, it will not be processed until the following month. I also authorize the General
Employees’ Retirement Fund to make adjustments to my account to correct any credit entries made
in error.
I am the member
I am a Power of Attorney or guardian, and documentation is attach or is on file
___________________________________
Signature
___________________________
Date
DIRECTIONS
This form is for
receiving
electronic payments from the
General Employees
’
Retirement
Fund
.
If you are a Power of Attorney or
guardian, you must attach a copy
of your legal documentation.
STEP 1
Complete the form by
typing information or print
in ink and sign.
STEP 2
Submit
your form:
A) During business hours,
Monday – Friday
8:00 AM – 4:00 PM,
With a photo ID
B) By faxing to:
813-274-7289
C) By mailing to: General
Employees’
Retirement Fund 306
E Jackson St, 7E
Tampa FL 33602
STEP 3
Forms
are
processed
during
mid month. Any forms
received after processing,
will be held and processed
for the following month.
You may call us for deadline
updates: 813-274-7850
THANK YOU!
OFFICE USE ONLY
Date Received:____________
Received By:______________
ID Verified:________________
Date Scanned:_____________
Last 4 Digits of
Social Security:
Pension
ID:
PART A. MEMBER INFORMATION
Member Name:
Address:
Email:
PART B. CANCEL CHANGE DISTRIBUTE TO 2 ACCOUNTS only complete 1 & 2 for split accounts
1. Account:
2. Account:
1. Amount:
2. Amount:
OFFICE USE ONLY
Processed By:_____________________ Checked By:____________________ Date Complete:_________________
Checking
Checking
Savings
Savings
______________________________________
__________
_______________
________________________________________________________________________________________
__________________________________ ________________________________________
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_________________________________
__________________
_________________________________
__________________
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