Direct Deposit Authorization Form - Louisiana

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www.lasersonline.org
Authorization for Direct Deposit
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
Fax 225.935.2856 · 225.922.0612 (hearing impaired)
Form 4-05
R062015
Today's DateLast NameMiddle NameMember's First Name
I hereby authorize the Louisiana State Employees' Retirement System (LASERS) to direct the net amount of my monthly benefit payment
to my account at the financial institution designated above. This authorization is not an assignment of my right to receive payment and
revokes all prior payment direction notifications applicable to these payments. Upon my death, if payments have been deposited to my
account that are not due, or if funds are credited to my account in error for any reason, I authorize: 1) LASERS to initiate electronic funds
transfer debit transactions to retrieve those payment; and 2) The financial institution (bank or credit union) to release to LASERS the status
of my account, my current mailing address, the names and mailing addresses of any joint account holder, and the names and mailing
addresses of individuals who have power of attorney relevant to those payments to withdraw funds from my account. If my death should
occur prior to the due date of any payment which is made by LASERS in compliance with the Authorization for Direct Deposit, the named
financial institution shall refund such payments to LASERS. I certify that I am entitled to the payment identified herein. Any joint signer
on the bank account listed below, accepts the responsibility of notifying LASERS of the death of the named Payee, and agrees to accept full
responsibility for returning any funds to LASERS which were transmitted by LASERS to the account after the death of the Payee.
By signing below, you certify that you have read the provisions of this form, and fully understand the obligations contained herein.
SECTION 1: ACCOUNT INFORMATION
4-05 R062015 RETAIN A COPY FOR YOUR RECORDS ERBER11 Page 1 of 1
Social Security Number
Name of Payee Social Security Number
Check at least one of the following options:
DROP/IBO Withdrawal
Monthly Retirement Benefit
SECTION 2: PAYEE AND JOINT ACCOUNT HOLDER'S SIGNATURE
Date
Email Address
Evening Area Code/Phone NumberDaytime Area Code/Phone Number
Zip CodeStateCityPayee's Mailing Address
Date of Retirement (if applicable)
Joint Account Holder's Signature
Name of Joint Account Holder (if applicable) Social Security Number
Payee's Signature Date
Name and Address of Financial Institution
Type of Account:
Checking
Savings
Depositor Account NumberRouting Number
Page 1/2
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Direct Deposit Authorization Form - Louisiana PDF

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