Authorization for Direct Deposit of Monthly Benefit (VRS-57)
AUTHORIZATION FOR DIRECT DEPOSIT OF MONTHLY BENEFIT
VIRGINIA RETIREMENT SYSTEM P.O. Box 2500 Richmond, VA 23218-2500 Toll-free 1-888-827-3847 Fax 804-786-9718
Clear Form
1. Social Security Number 2. Phone Number
If you are an agent under a Power of Attorney or a guardian for a retiree or survivor, please attach a copy of the Power of Attorney or guardianship papers. If you are filling this out on behalf of a retiree or beneficiary in the State Retiree Health Benefits Program and the address is being updated, the address change will not be made unless the Power of Attorney specifically authorizes access to health plan information.
If your mailing address changes, it is important that you notify VRS so you'll receive important information mailings, including the year-end tax statement and newsletters.
Note: If you receive more than one benefit from VRS, this authorization applies to all benefits you receive.
3. Name
(First, Middle Initial, Last)
4. Address (Street, City, State and ZIP+4)
Check here if a new address
5. Previous Account Number (If changing direct deposit information, enter the account number where funds were deposited prior to the change you are requesting.)
6. Financial Institution Name (Provide name here even if institution not changing)
7. Account Type (Choose one) Checking Savings
8. Financial Institution Account Information
Provide a voided check with the correct routing information and account number. To ensure the information you provide is accurate, you may wish to contact your financial institution.
TAPE VOIDED CHECK WITHIN THE LINES OF THIS BOX
9. Authorization and Signature (Required for Processing)
I hereby authorize VRS to deposit my monthly retirement benefit payment directly to my account at the financial institution shown above. I agree to provide written notification to VRS within 30 days of any changes to this information so that my monthly benefit may be properly distributed. I also authorize VRS to make adjustments to my account to correct any credit entries made in error.
Signature
Date
VRS-57 (Rev. 08/19)
*VRS-000057*
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- planning for retirement hostos community college
- 57 5 retirement plan for tier 4 members
- retirement benefits for federal law enforcement personnel
- special retirement provisions for law enforcement
- 62 5 retirement plan for tier 4 members new york city
- retiree annuity supplement fers chapter 51
- authorization for direct deposit of monthly benefit vrs 57
- federal employees retirement fers system usda
- retirement how to apply public employees retirement system
- calpers retirement benefits early through mid career
Related searches
- authorization for direct payment
- authorization for direct payments form
- computershare direct deposit of dividends
- direct deposit authorization form printable
- printable direct deposit authorization form
- dfas direct deposit authorization form
- request for direct deposit form
- direct deposit authorization form
- direct deposit authorization form fillable
- direct deposit authorization form pdf
- generic direct deposit authorization form
- ach direct deposit authorization form