Nycers F380 Form – Fill Out and Use This PDF

NYCERS USE ONLY	F380

*380*

Authorization for Electronic Fund Transfer (EFT) of Monthly

Retirement Allowance

Complete this form if you wish to have your NYCERS check automatically deposited into your bank (checking or savings) account by Electronic Fund Transfer (EFT). Be sure to read the instructions on the back of this form before submitting it to NYCERS. Should you have any questions, please contact our Call Center at 347-643-3000.

Member Number OR	Pension Number		Last 4 Digits of SSN			Daytime Phone
						(	)
First Name		M.I.		Last Name
Address							Apt. Number
City					State			Zip Code

Provide the banking information below and attach a preprinted personal check or deposit slip or a copy of your checking or savings account bank statement. Your name must appear on the preprinted check or bank document and it must match the name in NYCERS' records exactly in order for us to process this request.

I wish to deposit my monthly retirement allowance in my

Checking or

Savings

account. I have read and understand the

conditions on page 2 of this form and hereby authorize NYCERS to send my monthly retirement allowance via EFT.

BANKING INFORMATION (please print):
Bank Name	Phone Number

Branch Address

City

State

Zip Code

Account Number

Bank Routing Number

Signature of Member

Date

This form must be acknowledged before a Notary Public or Commissioner of Deeds

State of

County of

On this

day of

2 0

, personally appeared

before me the above named,

, to me known, and known to

me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she

executed the same, and that the statements contained therein are true.					If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission

If payments are transferred in error by NYCERS, the bank will return such payments to NYCERS as authorized by the depositor. The bank also agrees to apply the same procedures described in 31 CFR 210 to such transfers, and agrees to reimburse NYCERS to the same extent as Federal agencies are reimbursed under 31 CFR 210.

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NYCERS USE ONLY	F380

Filling out this form and submitting it to NYCERS authorizes:

1.The Office of the Comptroller of the City of New York, on behalf of the New York City Employees' Retirement

System (NYCERS) to send my monthly retirement allowance via Electronic Fund Transfer (EFT) to the bank* designated on this form for deposit in my account.

2.My bank: (a) to receive my monthly retirement allowance via EFT for deposit in my account AND

(b)to deduct from my designated account or deposits in my name at this bank all amounts transferred in error by NYCERS or any amounts sent after my death and to reimburse NYCERS to the extent of such deductions, applying the same procedures described in 31 CFR 210 to such transfers in error and reimbursing NYCERS to the same extent as Federal agencies are reimbursed under 31 CFR 210.

3.My heirs, my estate and designated beneficiaries of my monthly retirement allowance, respectively, to reimburse NYCERS for any

amount deposited in error after my death, in event that my account is closed or contains an insufficient balance to reimburse

NYCERS.

This EFT authorization will remain in effect until I have given written notice to NYCERS canceling the EFT.

* The bank you name must be a member of the Automated Clearing House in order for your funds to be deposited electronically.

HOW EFT WORKS:

1.Your net retirement allowance is automatically credited to your bank account on the last day of each month providing it's a business day; if the last day is a weekend or holiday, the funds are deposited on the next business day.

2.Your monthly net retirement allowance will appear on your bank statement.

3.A quarterly statement, issued by the Office of the Comptroller, will be mailed to your home address. It will reflect details of your monthly retirement allowance, including deductions for union dues, health insurance and federal income tax withheld during the three-month period.

Your monthly retirement allowance can be deposited in either your checking or savings account - NOT split between both.

TO AUTHORIZE EFT:

•Provide your personal and banking information on page 1.

•Attach a preprinted personal check

(name must appear on check) or preprinted savings deposit slip to this page. If your bank no longer provides personal checks or preprinted savings deposit slips, attach a copy of the top portion of your Checking or Savings Account Bank Statement.

•If submitting a preprinted check or deposit slip write VOID (in large letters) across the face, as indicated in the sample.

•Do NOT sign the check that you are attaching to this page.

•The name on your bank account must match exactly your name in NYCERS' records.

Note: It may take up to 45 days from receipt of this form for the account to be processed for EFT.

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