CSS2HTML: WEB7204.XDP

Note:  If funds are to be deposited into only one account, you MUST select the ALL box.  If a PERCENTAGE or DOLLAR AMOUNT is entered, you MUST provide the secondary account information below for the remaining balance.

Direct Deposit Authorization
SC Public Employee Benefit Authority

South Carolina Retirement Systems
PO Box 11960, Columbia, SC 29211-1960

City

Phone Number with Area Code

Check Payment Type:

First Name/Middle Name

State

Social Security Number

Payee Last Name 

Mailing Address

Zip Code

THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

1.  Primary Account Information:

Suffix

Check appropriate system:

Check appropriate box:

Member SSN:

The amount specified below will be directly deposited into this account.

Financial Institution Name

Transit/Routing Number

Account Number

OR     You may enter a percentage or dollar amount:

Financial Institution Name

Transit/Routing Number

Account Number

(OR mark with "X" with two witnesses OR Power of Attorney, if on file with the Retirement Systems)

(Note:  This form must be signed and dated.  See notes on Page 2.)

2.  Secondary Account Information:          The remaining balance will be directly deposited into this account.

Form 7204
Revised 11/14/2013
Sign in Blue ink

TAPE A VOIDED CHECK HERE   (No deposit slips or starter checks, please)

TAPE A VOIDED CHECK HERE   (No deposit slips or starter checks, please)

Payee's Signature 

Date 

If this account does not have checks, please attach a form from your financial institution certifying the account and routing numbers.

If this account does not have checks, please attach a form from your financial institution certifying the account and routing numbers.