DIRECT DEPOSIT AUTHORIZATION FORM
As a participant in the Central Valley Retiree Medical Trust (the “Trust” or “CVRMT”), you will be
entitled to receive reimbursement benefits, as explained in the “Medical Expense Reimbursement Plan” of
the Trust. The Trust Office offers direct deposit of your premium reimbursement benefit payments into
your personal bank account. If you do not select direct deposit, you will receive your premium
reimbursement benefit payments in the form of a check. If you would like to enroll for direct deposit,
please complete this document and return it to the Trust Office via fax, email or USPS.
If you are uncertain of the numbers you should use below in items 4 and/or 5, you can void one of your
checks and submit it with this signed document.
If you have any questions, please contact our office at the phone number or email address provided above.
By my signature below, I authorize the Trust Office to directly deposit my benefit payments into
my bank account held at the bank named below. This authorization will remain in effect until I
notify the Trust Office in writing.
1. Your Printed Name: _________________________________________________________
2. Bank Name: _______________________________________________________________
3. Bank Address: _____________________________________________________________
4. Account Number: __________________________________________________________
5. Routing Number: __________________________________________________________
6. Employer: ________________________________________________________________
7. Your Signature: ____________________________________________________________
8. Phone Number: ____________________________________________________________
9. Date: ____________________________________________________________________
Approved and Accepted for the CVRMT on ____________________ by the Trust Administrator.
(Date)
_____________________________________ ___________________________________
Trust Administrator (Signature) Trust Administrator (Print Name)
Administered by:
Benefit Programs Administration
1200 Wilshire Boulevard, Fifth Floor
Los Angeles, CA 90017-1906
Office: (833) 728-2747
Fax: (562) 463-5894
E-mail: centralvalley@bpabenefits.com
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