Fillable PERA DIRECT DEPOSIT AUTHORIZATION FORM

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PERA DIRECT DEPOSIT AUTHORIZATION FORM

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33 Plaza La Prensa
Santa Fe, NM 87507
(505) 476-9300 phone
(505) 954-0370 fax
www.nmpera.org
PERA DIRECT DEPOSIT AUTHORIZATION FORM
Instructions: Please print or type in dark ink. Required Fields are in
BOLD ITALICS
. Additional instructions are on the back page.
Check One: New Change In Existing Information
Check One: Retiree Co-Payee Beneficiary
SOCIAL SECURITY NUMBER or PERA ID NUMBER
HOME or CELL TELEPHONE NUMBER
NAME
First
Middle Initial
Last
MAILING ADDRESS
City
State
Zip Code
FINANCIAL INSTITUTION
You are hereby directed to electronically transfer my monthly benefit check to:
NAME of CURRENT FINANCIAL INSTITUTION (changing from)
NAME of NEW FINANCIAL INSTITUTION (changing to)
Check One
NEW ACCOUNT NUMBER
Savings Checking
NEW ROUTING NUMBER
AUTHORIZATION
I authorize PERA to make credit and debit entries to my account at the above named financial institution. I agree to notify PERA
immediately upon discovery of any errors resulting from transactions under this
authorization and of any changes that may affect
these instructions. I agree to hold PERA and the State of New Mexico harmless from any and all loss, cost, damage or expenses
suffered as a result of errors in credit or debit entries caused by persons not
employed by PERA. I direct the above named
financial institution on demand to refund and repay to PERA any deposits made to my account after my death
, the due date of
which is subsequent to my death.
Signature: Date:
YOU MUST ATTACH A VOIDED CHECK OR A COMPLETED DIRECT DEPOSIT FORM FROM YOUR
NEW FINANCIAL INSTITUTION HERE (Please do not include a copy of a deposit slip)
PERA DIRECT DEPOSIT AUTHORIZATION FORM
INSTRUCTIONS
A
nytime a PERA pension recipient needs to change their direct deposit information with PERA, they must complete a
PERA Direct Deposit Authorization Form. The pension recipient must complete the top portion of the form with their
personal information.
T
he Financial Institution box indicates that this is the financial institution you would like your benefit payment to be direct
deposited into. Print or type the name of your bank or financial institution. You may only have one account for your
direct deposit. PERA cannot split your benefit payment. Please check either box for the type of account (checking or
savings).
• T
he Authorization box indicates that you authorize PERA to make credit and debit entries to your account in t
he
financial institution account you included. Sign and date.
• You must attach a voided check or a completed direct deposit form from your financial institution. This will be
used to verify the account number. Do not include a copy of a direct deposit slip.
• P
lease return or mail the PERA Direct Deposit Authorization Form to PERA by the fifteenth (15th) day of the
month. If the PERA Direct Deposit Authorization Form is received after the fifteenth (15th) day of the month, the
change to your direct deposit information will take effect the following month.
November 2019
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PERA DIRECT DEPOSIT AUTHORIZATION FORM

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Completed 7 April 2021

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