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 AuthorizationSC Public Employee Benefit Authority
South Carolina Retirement SystemsPO 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:
(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 7204Revised 11/14/2013Sign in Blue ink
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.
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