ࡱ> $&# bjbjVV .B<< hhh5\5 .&}x>$;!tx}} $0 _"T_"_""(< _"h q: Form DA (Rev 12/01/09) State of Delaware  FORMCHECKBOX  New Address Pensioners Direct Deposit Authorization Form Name  CONTROL Forms.TextBox.1 \s  Social Security #  CONTROL Forms.TextBox.1 \s  Employee ID  CONTROL Forms.TextBox.1 \s  Address  CONTROL Forms.TextBox.1 \s  City, State, ZIP+4  CONTROL Forms.TextBox.1 \s  This form will override all previous forms. Please list ALL accounts where you wish to have monies deposited. We no longer require verification in the form of a voided check or bank statement. However, please be aware that YOU ARE RESPONSIBLE for ensuring that the routing and account numbers on this form are correct. Please contact your bank to confirm routing/account numbers if you are unsure. INCORRECT ROUTING AND/OR ACCOUNT NUMBERS WILL RESULT IN YOUR DIRECT DEPOSIT BEING DELAYED UNTIL THE NEXT SCHEDULED PENSION PAYMENT. To have your net Pension amount go to ONE account or to have the majority of your monthly Pension amount go to a primary account (with specific dollar amounts going to additional accounts listed below), complete the following:  FORMCHECKBOX  Deposit Net Monthly Pension Routing # Account # CIRCLE ACCOUNT TYPE: Amount into this account.  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  OR Bank Name  CONTROL Forms.TextBox.1 \s   FORMCHECKBOX  Use this account as primary with additional monies going Bank Address  CONTROL Forms.TextBox.1 \s  to accounts listed below. If you are using this form to change an existing direct deposit to a primary account and wish to have ALL other additional deposits (i.e. savings account deposits and/or credit union deposits) remain the same, Please check one  FORMCHECKBOX  Continue additional deposits OR  FORMCHECKBOX  Stop additional deposits and deposit all monies into the above account To have a specific dollar amount go to additional banks or credit unions, complete as many of the following as necessary: Deposit the Following $ Amount Routing # Account # CIRCLE ACCOUNT TYPE:  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  Bank Name  CONTROL Forms.TextBox.1 \s  Bank Address  CONTROL Forms.TextBox.1 \s  _________________________________________________________________________________ Deposit the Following $ Amount Routing # Account # CIRCLE ACCOUNT TYPE:  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  Bank Name  CONTROL Forms.TextBox.1 \s  Bank Address  CONTROL Forms.TextBox.1 \s  I understand that my monthly benefit amount will be direct deposited to the account(s) designated above so that the funds are available to me on the last working day of each month. _________________________________________  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  Signature of Pensioner or Power of Attorney Telephone Number Date Return form to the Office of Pensions, McArdle Building, 860 Silver Lake Blvd., Suite 1, Dover, DE 19904-2402 or fax completed form to (302) 739-6129. 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