TreasuryDirect Authorization Agreement Form for Savings Bonds

[Pages:1]U.S. Savings Bonds Payroll Deduction Program

You can purchase savings bonds through payroll deduction. Your first step is to set up your account with TreasuryDirect through the secure web-based system at . Once you receive an account number you will give the Mesa Public Schools Payroll department your account number and the amount that you wish to save each pay period. The deduction is sent just like direct deposit and is available on pay day. You do not automatically receive a bond. You will need to manage your bond purchases through the website at . Paper bonds are no longer sent out. For more information and to set up your account go to .

Return this form to the MPS Payroll department.

TreasuryDirect Authorization Agreement Form for Savings Bonds

Employee Information

Name: Employee Number:

Daytime Phone Number:

Account Information

TreasuryDirect account Deduction Code SB4 Checking

Circle one:

Name of Bank :

R/T: Bank Code 60

Bureau of the Public Debt O51736158

Account Number:

Dollar Amount Per Pay : $

START

STOP CHANGE

PLEASE NOTE: We will 'prenote' your TreasuryDirect account one pay period before we send your funds.

AUTHORIZATION AGREEMENT

I hereby authorize Mesa Public Schools to initiate automatic deposits to the account listed at the bank listed above. Additionally, I authorize Mesa Public Schools to make withdrawals from this account in the event of an error.

Furthermore, I agree not to hold Mesa Public Schools responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution, or due to an error on the part of my bank in depositing funds to my account.

This agreement will remain in effect until Mesa Public Schools receives a written notice of cancellation from me or my bank, or until I submit a new TreasuryDirect Authorization Agreement Form to the Mesa Public Schools Payroll Department.

Employee Signature:

Date:

Rev 09/2013

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