California Direct Deposit Form 3 - Free Download
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FOR UC HUMAN RESOURCES USE ONLY
TRANSIT ROUTING NUMBER ACCOUNT NUMBER TRANSACTION TYPE
INPUT BY DATE AUDITED BY DATE
SIGNATURE OF JOINT ACCOUNT HOLDER
DAT E
SIGNATURE OF PAYEE DATE
3. FOR COMPLETION BY PAYEE (You must attach a voided printed check. Do not attach a deposit slip.)
NAME OF FINANCIAL INSTITUTION ACCOUNT NUMBER
BRANCH NAME AND ADDRESS BRANCH TELEPHONE NUMBER
(City, State, ZIP)
Change my account. My current account will remain open until my new account is in effect.
Change my account. I have closed my account. Send my future checks to my mailing address until my new
account is in effect.
1. PERSONAL INFORMATION (Please complete entire section)
DIRECT DEPOSIT FOR MONTHLY BENEFIT
UCRS 160 (R8/12) University of California Human Resources
NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER DAYTIME PHONE
MAILING ADDRESS (Number, Street) CHANGE MY ADDRESS BENEFIT PAYMENT TYPE (Check one)
(City, State, ZIP, Country) STATUS (Check all that apply)
( )
Send completed form to:
UC Human Resources
P.O. Box 24570
Oakland, CA 94623-1570
BRANCH NAME AND A\DDRESS BRANCH TELEPHONE NUMBER BANK TRANSIT ROUTING NUMBER
SIGNATURE OF REPRESENTATIVE PRINT / TYPE REPRESENTATIVE’S NAME DATE
NAME OF FINANCIAL INSTITUTION ACCOUNT NUMBER (Show the number exactly as required for direct deposit.)
I certify that I am entitled to the payment identied above, and that I have read and under-
stand the information and instructions on this form. In signing this form, I authorize my
payments to be sent to my nancial institution and deposited to the account I have desig-
nated. If the account designated is a trust account, I also certify that the account tax I.D.
number is my Social Security number. I authorize UC Retirement Administration to debit my
account for any amounts transmitted in error or after my death. If the funds have been
withdrawn following my date of death, I authorize my nancial institution to release to UC
the name and address of the person(s) responsible for withdrawing the funds. I understand
that if deposits are being made to a joint account, the other account holder must sign
the “Joint Account Holder’s Certication” section (at right). I further agree that if the
account specied above becomes a joint account (or if the joint account holder changes), I
must complete a new form. I understand that this authorization will remain in effect until I
cancel it by submitting a new form.
I conrm the identity of the above-named payee and the account number. As a representative of the above-named nancial institution, I certify
that the nancial institution agrees to receive and deposit the payment identied above.
I certify that I have read this form. If the payee
named at left dies, I agree to refund to the
University any payments deposited in our
account that he or she was not entitled to receive.
(Please notify UCRS of the death of the UCRS
payee.)
SEE REVERSE FOR PRIVACY NOTIFICATIONS
MEMBER – PHOTOCOPY THIS FORM FOR YOUR RECORDS.
4. FOR COMPLETION BY FINANCIAL INSTITUTION
( )
( )
Action (check one):
New enrollment
Cancel direct deposit
5. CERTIFICATION AND AUTHORIZATION (Signature(s) required) JOINT ACCOUNT HOLDER’S CERTIFICATION
2. ACTION AND ACCOUNT TYPE
Use this form to begin, change or cancel the electronic deposit of your monthly benet. There may be a waiting period before your direct deposit
change takes effect, determined by monthly processing deadlines.
UCRP UC PERS VERIP UC 415(m)
YES NO
RETIRED / DISABLED
OTHER (NON-MEMBER)
SURVIVOR / CONTINGENT ANNUITANT
Account type for new enrollment or direct deposit change (check one):
Savings account (Complete Sections 4 and 5) Trust account (Must be grantor-type trust; tax I.D. number must be payee’s
SSN) check one box below:
Checking account (Complete Sections 3 or 4 and 5) Trust savings account (Complete Sections 4 and 5)
Trust checking account (Complete Sections 3 or 4 and 5)
