Employer
Debit
Authorization
4101 MacCorkle Avenue, SE
Charleston, WV 25304
304-558-3570 or 800-654-4406
www.wvrerement.com
Consolidated Public Rerement Board
I hereby authorize the State of West Virginia, hereinafter called STATE, to initiate debit entries within the scope of Consolidated Public
Retirement Board transactions, into my Checking account(s) as indicated above and the Financial Institution(s) named above,
hereinafter called DEPOSITORY. This authority is to remain in full force and effect until STATE has received written notification from me
of its termination in such time and in such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it.
Signature
Date
Updated July 2016
Street Address City State
FEIN
Contact Name
Section 2: Financial Information:
Telephone Number
Zip Code
Section 1: Employer Information
Employer Name
Please remember to attach a voided check for each different Account to be used.
Section 3: Signature Authorization:
Name of Financial Institution:
Routing Number:
Account Number:
Name of Financial Institution:
Routing Number:
Account Number:
Name of Financial Institution:
Routing Number:
A
ccount Number:
Email
Phone
Please return this completed form to the Employer Reporting Section at the address listed above. Contact CPRB if you have questions.
