Fill - Free fillable XXX-XX- Direct Deposit Enrollment Application RS 6370 Electronic (Monroe-Woodbury Central School District) PDF form

EDITING TEMPLATE

XXX-XX- Direct Deposit Enrollment Application RS 6370 Electronic (Monroe-Woodbury Central School District)

Electronic Funds Transfer

Direct Deposit

Enrollment Application

RS 6370

(Rev.05/21)

Received Date

Please type or print clearly

in blue or black ink

NYSLRS ID Social Security Number [last 4 digits]

Retirement System [check one]

Employees’ Retirement System (ERS)

XXX-XX-

Police and Fire’ Retirement System (PFRS)

See Reverse side for Information and Instructions

SECTION 1: TO BE REVIEWED AND CORRECTED BY PENSIONER:

Name: (First, Middle Initial, Last) Preferred Telephone Number: (Please Provide)

Address: (Including Street, City, State and Zip Code) Corrections: (If Any)

If you currently receive more than one type of payment from NYSLRS, as a Pensioner, Beneficiary or an Alternate Payee under a

Domestic Relations Order, we will only distribute payment for all benefits payable to you in one account. With this application all funds

you receive from the New York State & Local Retirement System (NYSLRS) will be deposited to the bank indicated on this application.

SECTION 2: T O BE COMPL

ETED BY PENSIONER:

I hereby request all future benefits which become payable to me from the New York State and Local Retirement Systems (NYSLRS) be

transferred to my account via Electronic Funds Transfer (EFT) Direct Deposit to:

Account Type: Checking (attach voided check to Section 3, or have Section 3 completed by your Financial Institution)

If your checks do not have your name imprinted on them, Section 3 MUST be completed by the

Financial Institution.

Savings- Section 3 MUST be completed by the Financial Institution.

NYSLRS is authorized to continue making such benefit payments to said financial institution or any of its successors until NYSLRS

receives written notice from me to the contrary. I agree that NYSLRS shall have no liability or responsibility for loss occasioned

by erroneous information supplied by myself, my duly authorized representative or the financial institution.

I expressly acknowledge and understand any payments made pursuant to this request will be strictly an accommodation made to me by

NYSLRS, and NYSLRS reserves the right to discontinue or decline to honor this EFT request without prior notice.

I hereby authorize and direct the financial institution, on my behalf, my joint account holder, if any, and my estate to charge my account

for amounts paid to which I was not entitled. I also agree, on behalf of myself, my joint account holder, if any, and my estate, that such

amounts will be returned to NYSLRS.

By making this request, I hereby represent the account identified herein (and as may later be modified) is not a trust.

Signature: _____________________________________________________ Date: ____________________________________

Signature of Joint Holder: (if any) ___________________________________ Date: ____________________________________

SECTION 3: TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION IF DIRECTING FUNDS INTO A SAVINGS ACCOUNT OR IF

A VOIDED CHECK IS NO

T ATTACHED. THE ABOVE PENSIONER’S NAME MUST APPEAR ON THE ACCOUNT.

Name of Account: (Full Title of Account)

(Verify Account Type in Section 2 is correct)

Transit/ABA N

umber: (ACH Format-9 Digits) Depositor’s Account Number: (EFT Format – Cannot Exceed 17 Digits)

Name of Financi

al Institution: __________________________________________________________________________________

Address: _________________________________________ Telephone Number: (________) __________ - __________________

City: _____________________________________________ State: ______________________ Zip Code: _______ - _________

I, as a representative of the above named financial institution, agree to abide by the NACHA Rules and Regulations. Amounts paid to

account holder to which he/she is not entitled will be returned to NYSLRS. Liability shall be limited as prescribed in the NACHA Rules

and Regulations.

Bank Officer Signature: __________________________________ Bank Officer: (Please Print) _____________________________

RS 6370 (Rev. 05/21)

(Page 1 of 2)

*05/21RS6370*

PLEASE READ CAREFULLY

Enrollment Application:

NYSLRS provides direct deposit through the National Automated Clearing House Association (NACHA) Network which facilitates batch

payment processing within the U.S. to domestic U.S. financial institutions. We do not transfer funds into international accounts across

national borders.

NYSLRS will not make a direct deposit of a monthly pension payment into a trust account or any trust-like entity (i.e. Payable on Death

Account). Section 110 of the Retirement and Social Security Law provides that the right of a person to a pension shall be unassignable. A

trust, living or otherwise, is a separate legal entity that holds property or assets. Accordingly, the direct deposit of your pension benefit

into a trust account would constitute an impermissible assignment under the law.

NYSLRS will not make direct deposit of a monthly pension payment to a pre-paid debit card. Since there is no personal bank account

created and personally held by you when using a prepaid debit card, this too would be considered an impermissible assignment of

benefits, not allowed by law.

The Electronic Funds Transfer Direct Deposit Enrollment Application must be signed by you and the joint account holder if any. Review

Section 1 and make any necessary corrections and complete Section 2. If you are requesting direct deposit to a "Checking Account",

attach a voided check to Section 3. If a voided check is not attached to Section 3, or if your checks do not have your name imprinted on

them, then Section 3 must be completed by your financial institution. If requesting direct deposit to a "Savings Account", Section 3 must

be completed by your financial institution. Return the application to NYSLRS.

Pensioner and Joint Account Holder Authorization for Recovery of Funds Deposited in Error:

By signing this Electronic Funds Transfer Direct Deposit Enrollment Application, both for yourself and your estate, and each joint account

holder, if any, you consent to allow NYSLRS, through the designated financial institution, to debit your account in order to recover any

NYSLRS benefits to which you were not entitled. This means of recovery shall not prevent NYSLRS from utilizing any other lawful means

to retrieve NYSLRS benefit payments to which you were not entitled.

Changing Financial Institutions and/or Accounts:

You may change financial institutions and/or accounts by completing a new enrollment application. The new enrollment application, when

processed, will cancel the enrollment at the previous financial institution or your prior account. You should, however, be aware that

changing financial institutions and/or account could take up to 30 days to complete. We recommend that the old account not be closed

until the first deposit is made to your new account or financial institution.

Cancellation of Electronic Funds Transfer Direct Deposit:

To cancel this request, written notification from you must be received by NYSLRS at least 30 days prior to the next payment date.

The financial institution may terminate the electronic funds transfer direct deposit agreement with a written notice 30 days in advance of

the cancellation date. The financial institution cannot cancel the authorization without notification to both you and NYSLRS.

The New York State and Local Retirement System reserves the right to discontinue or cancel this electronic funds transfer direct deposit

agreement at any time. Written notice will be provided to you.

The completed applications should be returned to the following address:

EFT/Pensioner Services

New York State and Local Retirement System

110 State Street

Albany, New York 12244-0001

Or you may fax the completed form and any attachments to (518) 473-5323.

Questions or problems should be directed to the address above or you may call us at (518) 474-7736 or toll free at 1-866-805-0990.

New York State Personal Privacy Law Notification:

The New York State and Local Retirement System (NYSLRS) requests personal information on this form to operate the

NYSLRS/Electronic Funds Transfer Program. This information is being requested pursuant to State Finance Law 200(4) and Part 102 of

Title 2 of the New York Codes, Rules and Regulations. The information will be provided to the designated financial institution(s) and/or

their agent(s) for the purpose of processing payments, and for other official business of NYSLRS. No further disclosure of this information

will be made unless such disclosure is authorized or required by law. A retiree's failure to provide the requested information may delay or

prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program. The information provided will be

maintained in NYSLRS under the direction of the Pensioner Services Section of the Benefit Calculation and Disbursement Services

Bureau

RS 6370 (Rev. 05/21)

(Page 2 of 2)

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

Me

NAME

EMAIL

XXX-XX- Direct Deposit Enrollment Application RS 6370 Electronic (Monroe-Woodbury Central School District)

View Audit Log
Print With Audit Log
Duplicate Document

Fill is the easiest way to complete and sign PDF forms online. Upload your own documents or access the thousands in our library.

Get started with our no-obligation trial. Cancel at any time.

Fill in and edit forms

Fill in your choosen form

Full e-signing supported

Sign the form using our drawing tool

Download or print completed PDF

Send to someone else to fill in and sign

card number

expiry date

CVC

$0 per month

No obligation
Cancel anytime