Georgia Direct Deposit Form 1 - Free Download
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RETIREMENT PLAN TYPE (Mark X in Appropriate Box)
Name: ___________________________________________________ SSN:
(Last) (First) (MI) (Maiden)
Daytime Phone Number: (_____) __________________________ E-mail Address: _______________________________________
Mailing Address: ____________________________________________________________________________________________
(Street) (City) (State) (Zip Code)
Please update ERS system to reect the above address.
SECTION 1 - RETIREE INFORMATION
SECTION 2 - DIRECT DEPOSIT AUTHORIZATION
INSTRUCTIONS:
Before signing this agreement, please read the special conditions on page 2.
SECTION 4 - ERSGA USE ONLY
Retirement Number: ______________________ Date Veried: ___________________ Initials: ______
SECTION 3 - DIRECT DEPOSIT INFORMATION
Employees’ Retirement System (ERS)
Public School Employees Retirement System (PSERS)
Georgia Legislative Retirement System (LRS)
Georgia Judicial Retirement System (GJRS)
Georgia Military Pension Fund (GMPF)
Georgia Dened Contribution Plan (GDCP)
Direct Deposit of Net Monthly Benet
I authorize the Employees’ Retirement System of Georgia to electronically deposit my net monthly benet into my bank ac-
count. I have read and I understand the stipulations on the second page of this form, and I also understand that the following
conditions apply:
●My check can only be deposited into an account for which I am an account holder.
●ERSGA is authorized to adjust any entries made in error.
●This arrangement remains in effect until I cancel or change it in writing to ERSGA.
●I agree to immediately notify ERSGA of any change in my home address.
●Failure to abide by these conditions can jeopardize deposit of my monthly benet.
__________________________________________ ______________________________
Signature Date
INSTRUCTIONS:
Please check in the appropriate box indicating whether the account is a Checking Account or a Savings Account.
□ CHECKING
A voided pre-printed check must be
attached. Starter checks will not be
accepted.
□ SAVINGS Please provide the following information:
Financial Institution
___________________________________
Account Number ______________________________________
9-Digit Routing or Transit Number _______________________
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