Dfs A1 26R Form – Fill Out and Use This PDF

Please leave this area blank

STATE OF FLORIDA

DIRECT DEPOSIT AUTHORIZATION

PLEASE TYPE OR PRINT CLEARLY

Payee Social Security Number

–

–

Payee Last Name,

First Name

M.I.

Payee Home Mailing Address (Number, Street)

City

State

Zip Code

Home Telephone

Other Telephone (work, cell, etc.)

(____)

(____)

Direct Deposit

(1)

Start



Action Requested

(2)

Change





(Check Only One)

(3)

Name Change Only

(4)

Stop



For State of Florida Retirement Benefits Only.

NOTE: If you were a State employee and already had DIRECT DEPOSIT, no additional authorization is needed for your retirement benefit, unless you cancelled your previous authorization.

Account Type

(1) Checking



(Check Only One)

(2) Savings



Your Account Number – Start at left, leave unused spaces blank

Transit Routing Number of Your Financial Institution

Name of Your Financial Institution

Telephone number of Financial Institution

(____)

Signature of Payee or Legal Representative

Date

THIS FORM MUST BE SIGNED AND DATED BY PAYEE

Signature above signifies acceptance of the terms and conditions in

AGREEMENT to the right.

PLEASE READ AND CAREFULLY FOLLOW INSTRUCTIONS! For a Start or Change all boxes must be completed; do not leave information blank!

This form will start, change, or stop direct deposit for all payments received by you from the State of Florida. You may not have direct deposit to more than one account at one time.

Name: Please be sure your last name on this form matches the last name on your retirement account at the Division of Retirement. Your direct deposit will not start if the names do not match. If you change your name please contact the Retirement office ASAP for instructions on how to update your name in their files.

Address: Please notify the Division of Retirement of any address changes or corrections by calling toll free 1-888-377-7687 or local (850) 488-4742, writing PO Box 3090, Tallahassee, FL 32315-3090 or E-Mailing them at Retired@dms.myflorida.com for more information.

Direct Deposit Action Requested:

1.Check Start if you don’t have direct deposit and wish to start.

2.Check Change if you have direct deposit and wish to change your financial institution or just your account number or account type (Checking or Savings). Your current direct deposit is stopped when a change request is received. While the change is being processed, you will be paid by warrant (paper check).

3.Check Name Change Only if you are changing your name. Please notify the Division of Retirement ASAP. Skip to the bottom of the form and sign and date it.

4.Check Stop if you wish to stop your direct deposit. Stops are processed the day they are received.

Account Number: Please make sure the account number on this form is correct.

Transit Routing Number: This is the nine-digit number that identifies your financial institution (Bank, Savings & Loan or Credit Union). It is found in the bottom left-hand corner of your personal check.

If you’re not sure about your Account information , PLEASE CONTACT YOUR FINANCIAL INSTITUTION.

AGREEMENT

I hereby authorize and request the State of Florida to initiate credit entries and, if necessary, a debit entry reversing a credit entry made in error, to my account at the financial institution named. This direct deposit is to remain in effect until withdrawn by: (a) me in writing with sufficient notice to the State to allow adequate time to effect termination; (b) my death or legal incapacity; (c) the financial institution or (d) the State of Florida. It will purge approximately six (6) months after my last state retirement payment. It will remain in effect if I start receiving FRS benefits within 6 months of the final state wage payment.

Special Note: Please make sure your direct deposit has stopped before closing your account. Otherwise, the funds will be returned to the State and cause a seven to ten day delay before you receive your retirement payment in the mail.

Forms with deposit slips attached will be rejected;

the banking codes are not correct.

Tape a voided personal check here for verification.

If using a savings account, please verify account

information with your financial institution.

FAX to:	Or mail to:
(850) 413-5549	Direct Deposit Section
If you fax your form, retain	Department of Financial Services
the original. Please do not	200 E. Gaines Street
mail it.	Tallahassee, FL 32399-0359

Direct Deposit Telephone (850) 413-5517

Please allow 4 to 6 weeks for your direct deposit to begin.

DFS-A1-26R, Rev. Jan 2011