I.B.E.W. PENSION BENEFIT FUND ELECTRONIC ... - IBEW Local 86
I.B.E.W. PENSION BENEFIT FUND ELECTRONIC FUNDS TRANSFER AUTHORIZATION
PHONE NUMBER: 1-800-733-4239
I, the undersigned benefit recipient__________________________________________________(print name),
Whose address is___________________________________________________________________(street)
____________________________________________________________________(city)
_________________________________________________________________(state, zip) authorize the monthly pension payable to me under the terms of the IBEW Pension Benefit Fund plan(s) to be electronically transferred through the Automated Clearing House ("ACH") to the bank listed below. This instruction should remain in effect until canceled in writing. NOTE: The Bank address below should be the BANK-BY-MAIL address.
(Bank ? by ? Mail Name) _____________________________________________________
(Bank ? by ? Mail Street) _____________________________________________________
(City, State and Zip Code)_____________________________________________________
-Checking or
Your Account Number________________________________________________ -Savings
___________________________________________ Print Name
___________________________________ Social Security Number
___________________________________________ Signature
___________________________________ Telephone Number
If you are receiving a Survivor's benefit, please complete the following:
__________________________________________ Deceased Retiree's Name
_________________________________ Deceased Retiree's Social Security Number
The following section of this form must be completed by your bank
The bank agrees to refund to the Custodian any payment(s) received and credited to the account in error or subsequent to the date of his/her death, to the extent funds are available in the account.
By:___________________________________________________(Bank Representative's Signature)
Print Name and Title ________________________________________________________________
Dated: ________________________ Bank's Telephone Number: ( ) ______________________
Bank's ACH Routing/Transit Number ___________________________________________________
Return completed form to:
Internal Use Only
__________
BNY MELLON BENEFIT DISBURSEMENTS
P.O. Box 569
PBF00M
Pittsburgh, PA 15230-0569
Fax: 877-852-3027 Email:bdpensionphone@
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