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Directdeposit - NPERS3700 DIRECT DEPOSIT

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NPERS3700
Rev. 04/2018
Page 1 of 1
BAR CODE
Name
LAST FIRST MIDDLE
Date of Birth
PLAN TYPE
(Check All That Apply)
Social Security Number
Email
SCHOOL
STATE
COUNTY
JUDGES
PATROL
DCP
Home Phone
Work Phone
Employer
FINANCIAL INSTITUTION
Name:
Checking Savings
City:
State:
Zip:
NOTE: This authorization is to remain in effect until the Nebraska Public Employees Retirement Systems
receives notice of change. This notice of change must be received at least 30 days prior to the change
effective date.
If you are unable to secure a bank account, please contact NPERS for further options.
A SIGNATURE IS REQUIRED FOR AUTHORIZATION OR CHANGE.
X
Member’s
Signature: Date:
Direct Deposit
CHECK ONE
→
I am requesting direct deposit for my: Monthly Benefit Lump Sum Refund
AUTHORIZATION FOR DIRECT DEPOSIT OR CHANGE IN ACCOUNT
I authorize the Nebraska Public Employees Retirement Systems to initiate direct deposit entries to my checking/
savings
account at the Financial Institution indicated below:
This direct deposit account will be established or changed as soon as possible, and you will receive confirmation of the
change. This form must include your signature.
Attach voided check here.
(Please use tape only. DO NOT STAPLE.)
Failure to attach a voided check may delay the implementation of your
direct deposit request.
FOR DIRECT DEPOSIT INTO A
CHECKING ACCOUNT:
You MUST attach a voided check
to this form in order to initiate
direct deposit to your financial
institution.
(NOTE: Voided deposit slips will not
be accepted because all required
account information may not be
present.)
FOR DIRECT DEPOSIT INTO A
SAVINGS ACCOUNT:
We require documentation from your financial institution (such as an account statement), which lists your account number and the
routing number of the financial institution.
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Directdeposit - NPERS3700 DIRECT DEPOSIT

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Completed 7 April 2020

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