BOARD OF EDUCATION RETIREMENT SYSTEM E 65 COURT …

RETIREES EFT AUTHORIZATION

BOARD OF EDUCATION RETIREMENT SYSTEM

E

OF THE CITY OF NEW YORK 65 COURT STREET

Processing Date BERS USE ONLY

BROOKLYN, NEW YORK 11201-4965

OFFICIAL DATE OF RECEIPT

First Name

MI Last Name

Date of Birth

REQUIRED ? Email Address

Additional Telephone Number

Home Telephone Number

Did you retire within the last three months? Yes

No

Month of your retirement: _______________ Year of your retirement: ___________

ACKNOWLEDGEMENT

I hereby authorize the Office of the Comptroller of the City of New York, on behalf of the Board of Education Retirement System of the City of New York (BERS), to send my monthly pension and/or Tax Deferred Annuity benefits via Electronic Fund Transfer (EFT) to the bank (designated on reverse side) for deposit in my account. I understand that EFT may be made to my accounts whether individual or joint.

If, through an error, an overpayment is credited to my account, I hereby authorize the bank to adjust my account by a deduction equal to the amount of the overpayment and if, in that event, the balance of my bank account is insufficient, I, my joint account holder, my heirs and my estate hereby assume full responsibility upon demand to reimburse BERS to the extent of such overpayment.

This authorization will remain in full force and effect until I have canceled it in writing.

I understand that I must give the Office of the Comptroller and BERS a reasonable period of time to act on this authorization or its cancellation.

*The bank you name must be a member of the Automated Clearinghouse (ask your bank manager about this).

Signature:

Date:

Joint Signature:

STATE OF_____________________________________ COUNTY OF________________________________________

On this_______ day of ________,___________, personally appeared before me the said ________________________________ , to me known to be the individual described in and who executed the foregoing document, and he (she) duly acknowledged to me that he (she) executed the same, and the statements contained therein are true.

7777777707070700077763434255573100750625537762302307322037111063025073431333650265000767753572711667407603137361126500077672706035777000777777707000707007 4444444404040400040404444004444000444440044040444404004440444400440040044400444040000440400400440000004000004000400004044444040444444040444444404000404004

QFQ8F1811144-- --

________________________________________________ Notary Public or Commissioner of Deeds

(If you have an official seal, please affix it).

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RETIREES EFT AUTHORIZATION

Please attach either a voided check or a savings deposit slip. If you choose to have EFT deposits made to your checking account, attach to this authorization form one

of your personal checks with the word "VOID" written by you in large letters across the check's face. DO NOT SIGN THE CHECK. If you choose to have deposits made to your savings account, attach to this authorization form a deposit slip bearing your savings account number.

BANK INFORMATION TO BE COMPLETED BY THE BANK OFFICER

Bank's Name

Branch Address

City Account Number

State

Zip Code

Checking

Savings

Type of Account

Transit Routing/ABA Number (Must be 9 Numbers)

If payments are transferred in error by the Board of Education Retirement System of the City of New York (BERS), the bank will return such payments to BERS as authorized by the depositor. In addition, the bank agrees to apply the procedures described in 31 CFR 210 to such transfers and agrees to reimburse SEAS to the same extent as Federal agencies are reimbursed under 31 CFR 210. It is further agreed that this authorization is applicable to the depositor's accounts, whether individual or joint.

Officer's Name Officer's Signature

Telephone Number

Retiree's Initials

7777777707070700077763434255573100750625537762302307322037111063025073431333650265000767753572711667407603137361126500077672706035777000777777707000707007 4444444404040400040404444004444000444440044040444404004440444400440040044400444040000440400400440000004000004000400004044444040444444040444444404000404004

QFQ8F1811144-- --

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