Illinois Direct Deposit Form 3 - Free Download
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Illinois Direct Deposit Form 3
Illinois Direct Deposit Form 3
Application for Direct Deposit
IMRF Form 1199 (Rev. 07/07)
This form should be completed by the Benet Recipient (IMRF member or person
receiving the IMRF benet payment).
Name Social Security Number
_____________ — ________ — _____________
Address (Number, Street) City State Zip
Is this a new address Telephone Number
Yes No ( )
Account InformationImportant: The name of the person who will receive the IMRF
benet payments must be on this account. Please provide the information requested
below. If you are unsure of any of the requested information, contact the nancial
institution where you have your account. (See the back of this form for more information.)
Name of Financial Institution Branch Telephone Number
( )
Branch Address (Number, Street) City State Zip
Account Number
Financial Institution Routing Number Type of Account
Checking Savings
Member Service Representatives 1-800-ASK-IMRF (1-800-275-4673)
IMRF Form 1199 (Rev. 07/07)
I authorize and request the Illinois Municipal Retirement Fund to direct IMRF recurring payments for crediting to my account
at the nancial organization designated above. This authorization is not an assignment of my right to receive payment and
revokes all prior payment direction notications applicable to these payments. I understand that the nancial organization
designated reserves the right to cancel this agreement by notice to me; however, this authorization will remain in effect with
IMRF until cancelled by notice from me or by my death. Further, I understand and agree that IMRF will stop direct deposit
if I fail to keep IMRF informed of my current address. I also permit the release by the bank or nancial institution of my
current address to IMRF. I understand that a new Form 1199 is required if I change my nancial institution, my account
number or my name.
X_______________________ _________
Signature of Benet Recipient, Power of Attorney*, or Guardian* Date
*Attach court documents if not already submitted
Fax your completed form to IMRF at 630-368-5398 or mail it to:
Illinois Municipal Retirement Fund, 2211 York Road Suite 500, Oak Brook IL 60523-2337
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Illinois Direct Deposit Form 3