Michigan Direct Deposit Form 1 - Free Download
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Department of Technology, Management & Budget
Office of Retirement Services
www.michigan.gov/ors (800) 381-5111
P.O. Box 30171
Lansing MI 48909-7671
R0277X (Rev. 6/2012)
Authority, as amended: 1980 P.A. 300; 1943 P.A. 240; 1986 P.A. 182; 1992 P.A. 234
*000095000000000E*
Direct Deposit Application
For Pension Recipients
NAME (LAST, FIRST, M.I.) MEMBER ID OR SSN DAYTIME TELEPHONE
( )
MAILING ADDRESS
IS THIS IS A NEW ADDRESS
NO YES, please change
I receive more than one payment from ORS NO YES
If YES, I wish to have this direct deposit change apply to:
All payments to me
Other
(
s
p
ecif
y)
CITY, STATE, ZIP CODE
Use this form to 1) change either the account number(s) or the financial institution(s) for your direct deposit or 2) sign up
for direct deposit if you did not choose it earlier. If you receive more than one monthly pension payment from the
Office of Retirement Services (ORS), the bank account(s) identified below will be used for ALL pension payments
unless you specify a single account in the box above.
By submitting this completed form, I authorize ORS to deposit my net monthly pension by direct deposit into the designated
financial institution(s) and account(s). This authorization remains in effect until canceled by: a) me; b) my death or legal
incapacity; c) the financial institution; or d) the state of Michigan.
Financial Institution and Account Designation
You can have your pension payment sent electronically to one or two accounts, either at the same or different financial
institutions as you specify below. The instructions on the back will help identify routing and account numbers. If you
previously split your pension payment between two accounts and are changing only one of those accounts, you must
complete the details for both the accounts again. This will help prevent any confusion as to where the funds are to go.
NAME OF FINANCIAL INSTITUTION #1
INSTITUTION’S TELEPHONE NUMBER
( )
FINANCIAL INSTITUTION MAILING ADDRESS CHECK ONLY ONE
CHECKING SAVINGS
CITY, STATE, ZIP
INSTITUTION #1 PENSION AMOUNT
________% OR
BANK ROUTING NUMBER (CANNOT START WITH “5”) ACCOUNT NUMBER
NAME OF FINANCIAL INSTITUTION #2 (If this is the same as Institution #1, write “SAME” below.)
INSTITUTION’S TELEPHONE NUMBER
( )
FINANCIAL INSTITUTION MAILING ADDRESS
CHECK ONLY ONE
CHECKING SAVINGS
CITY, STATE, ZIP
INSTITUTION #2 PENSION AMOUNT
Balance of Pension
BANK ROUTING NUMBER (CANNOT START WITH “5”) ACCOUNT NUMBER
I authorize ORS to recover money electronically deposited in my account(s) in error, either by adjusting the account(s) or withholding
any future payments. I understand I will be notified in writing if adjustments are made. (Sign below to complete form.)
Signature: ____________________________________________________ Date: __________________________
Return your completed form and any attachments to:
ORS, P.O. Box 30171, Lansing, MI 48909-7671
