Louisiana Direct Deposit Form 3 - Free Download
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Name of joint signer (if any): Last, fi rst, MI, suffi x (Jr., III, etc.)
Relationship to recipient Telephone
Street address only City, state, zip
Teachers’ Retirement System of Louisiana
8401 United Plaza Blvd, Ste 300 • Baton Rouge, LA 70809-7017
PO Box 94123 • Baton Rouge, LA 70804-9123
Telephone: (225) 925-6446 • Fax: (225) 925-4779
www.trsl.org
Direct Deposit of Benefi ts
Form 15D (1/13)
Name: Last, fi rst, MI, suffi x (Jr., III, etc.)
Telephone
Mailing address:
City, state, zip
Email address
Return original or fax to Teachers’ Retirement System of Louisiana
Section 1 — Benefi t recipient information
Name of fi nancial organization
Address: Street / P.O. Box
City, state, zip
Form may not
be altered
Do not use for DROP
or ILSB withdrawals
Recipient’s signature (Do not print or type) Date signed (mm-dd-yyyy)
Section 3 — Financial institution agreement
I authorize and request Teachers’ Retirement System of Louisiana (TRSL) to direct the net amount of my monthly benefi t payment for crediting to my account at the
fi nancial organization designated below. This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notifi cations
applicable to these payments. This authorization will remain in effect until canceled by written notice from me to TRSL.
My signature authorizes TRSL to initiate electronic funds transfer debit transactions to retrieve payments sent, but not due, in the event that my death has occurred
or if I become employed in the fi eld of education, public or private, while receiving disability benefi ts, or if I am no longer a full-time student.
I further authorize the fi nancial organization designated below to release to TRSL, upon request, any and all information regarding my bank account designated
below.
Social Security number
Bank account number Checking Savings ATM
ACH routing number
In consideration of Teachers’ Retirement System of Louisiana (TRSL) making payments in accordance with the foregoing request without requiring the personal en-
dorsement of the payee, we hereby agree to repay, subject to disposition required by law and banking guidelines, the amount of any funds on deposit in the recipi-
ent’s account at the time of demand that are due TRSL by reason of death of the retiree. We further agree to accept the certifi cation of TRSL as to the date of death
of such payee as suffi cient evidence of date of death. In the event that we learn of the payee’s death before TRSL, we agree to notify TRSL of the death and return
any payments received after the death of payee to the extent that funds are available.
Dated at _________________________________________________ this _______________ day of ________________________________________________ , _________________.
Signature of fi nancial offi cer (Do not print or type) Name and title of fi nancial offi cer (Print or type) Telephone Toll-free number
( )
( )
( )
10-15D
Social Security number
If you are receiving multiple benefi t payments, check ONE only
(no selection indicates change will be applied to all accounts):
Change applies to ALL benefi t payments
Change applies to RETIREE benefi t payments only
Change applies to SURVIVOR/BENEFICIARY
payments only
Section 2 — Information about joint signer (if applicable)
Direct deposit payment stubs are mailed only when one of the following occurs: (1) establishment of direct deposit, (2) change in net pay, or (3) at the end of the
calendar year.
TRSL offers Member Access, which gives you secure, online access to your retirement account. To register, visit www.trsl.org, and follow the easy instructions.
Please check one:
This is a new direct deposit
setup or a change to a new
bank. (Section 3 required)
This is a change of my
account number with my
same bank. (Bank signature
not required)
Check here if address change
NOTE: For additional joint signers, complete TRSL’s Addendum to Direct Deposit of Benefi ts — Nonspousal Joint Signer(s) (Form 15JS).
