Ucrs 160 Form – Fill Out and Use This PDF

NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

DAYTIME PHONE

(

)

MAILING ADDRESS (Number, Street)

CHANGE MY ADDRESS

BENEFIT PAYMENT TYPE (Check one)

YES

NO

UCRP

UC PERS VERIP

UC 415(m)

(City, State, ZIP, Country)

STATUS (Check all that apply)

OTHER (NON-MEMBER)

RETIRED / DISABLED

SURVIVOR / CONTINGENT ANNUITANT

Checking account (Complete Sections 3 or 4 and 5)

Trust savings account (Complete Sections 4 and 5)

Trust checking account (Complete Sections 3 or 4 and 5)

NAME OF FINANCIAL INSTITUTION

ACCOUNT NUMBER (Show the number exactly as required for direct deposit.)

(

)

BRANCH NAME AND A\DDRESS

BRANCH TELEPHONE NUMBER

BANK TRANSIT ROUTING NUMBER

SIGNATURE OF REPRESENTATIVE

PRINT / TYPE REPRESENTATIVE’S NAME

DATE

5. CERTIFICATION AND AUTHORIZATION (Signature(s) required)

JOINT ACCOUNT HOLDER’S CERTIFICATION

I certify that I am entitled to the payment identiied above, and that I have read and under-

I certify that I have read this form. If the payee

stand the information and instructions on this form. In signing this form, I authorize my

named at left dies, I agree to refund to the

payments to be sent to my inancial institution and deposited to the account I have desig-

University any payments deposited in our

nated. If the account designated is a trust account, I also certify that the account tax I.D.

account that he or she was not entitled to receive.

number is my Social Security number. I authorize UC Retirement Administration to debit my

(Please notify UCRS of the death of the UCRS

account for any amounts transmitted in error or after my death. If the funds have been

payee.)

withdrawn following my date of death, I authorize my inancial institution to release to UC

the name and address of the person(s) responsible for withdrawing the funds. I understand

that if deposits are being made to a joint account, the other account holder must sign

the “Joint Account Holder’s Certiication” section (at right). I further agree that if the

account speciied above becomes a joint account (or if the joint account holder changes), I

must complete a new form. I understand that this authorization will remain in effect until I

cancel it by submitting a new form.

SIGNATURE OF JOINT ACCOUNT HOLDER

SIGNATURE OF PAYEE

DATE

DATE

FOR UC HUMAN RESOURCES USE ONLY

TRANSIT ROUTING NUMBER

ACCOUNT NUMBER

TRANSACTION TYPE

INPUT BY

DATE

AUDITED BY

DATE

SEE REVERSE FOR PRIVACY NOTIFICATIONS

MEMBER – PHOTOCOPY THIS FORM FOR YOUR RECORDS.