Maryland Direct Deposit Form 1 - Free Download
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Maryland Direct Deposit Form 1
Maryland Direct Deposit Form 1
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
DIRECT DEPOSIT — ELECTRONIC FUNDS TRANSFER SIGN-UP FORM
If you need assistance in completing this application, telephone a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.
SECTION I
To Be Completed by Payee
Directions for Payee:
1) Please read the instructions printed on the following page.
2) Complete SECTION I.
3) Provide this form to your financial institution so that they may
complete Section II.
* Advise the Maryland State Retirement Agency (SRA) of
change of home address to receive important information
regarding benefits and taxes.
A. SOCIAL SECURITY NUMBER OF PAYEE
B.
C.
D.
E.
F.
G.
NAME OF PAYEE (last, first, middle initial)
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE + 4
AREA CODE TELEPHONE NUMBER
PRINT OR TYPE REPRESENTATIVE’S NAME:
SIGNATURE OF REPRESENTATIVE:
AREA CODE/TELEPHONE:
DATE:
If you are receiving more than one payment from the
SRA please indicate which payment this EFT applies to:
RETIREE BENEFICIARY ALL
DATE THAT ELECTRONIC FUND TRANSFER
SHOULD BEGIN.
Check here only if your entire payment amount is subject
to being transferred to a foreign bank account. See
reverse side for more information.
PAYEE CERTIFICATION
I certify that I am the payee identified above, and that I have
read and understood the instructions on this form. In signing
this form, I authorize my pension payment to be sent to the
named financial institution to be deposited to the designated
account.
SIGNATURE OF PAYEE: DATE:
JOINT ACCOUNT HOLDERS’ CERTIFICATION
I certify that I have read and understood the instructions on
this form including the SPECIAL NOTICE TO JOINT
ACCOUNT HOLDERS.
SIGNATURE OF JOINT ACCOUNT HOLDER: DATE:
FORM 85 (REV. 6/10) www.sra.state.md.us
SECTION II
To Be Completed by Financial Institution
Directions for Financial Institution:
1) Verify information in SECTION I.
2) Complete SECTION II.
3) Send completed form to:
Maryland State Retirement Agency
ATTN: EFT Department
120 East Baltimore Street
Baltimore, MD 21202-6700
or fax to: EFT Department at 410-468-1700
H.
I.
J.
K.
L.
NAME AND ADDRESS OF FINANCIAL INSTITUTION
ROUTING NUMBER CHECK
DIGIT
DEPOSITOR ACCOUNT TITLE
TYPE OF ACCOUNT SRA USE
Place “X” in only one box ONLY
CHECKING ACCOUNT 22
SAVINGS ACCOUNT 32
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the named payee(s) and the account
number and title. As representative of this financial institution,
I certify that the financial institution agrees to receive and
deposit the payment as identified.
PAYEE’S ACCOUNT NUMBER
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