DRS MS 145 (R 4/10)
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Important: Before completing this form, please read the instructions on the back. Due to federal restrictions, we
cannot transfer funds electronically if the funds will be immediately credited to an account outside of the United States.
Section A: To be completed by payee
Payee Name (Last, First, Middle)
Payee Social Security Number
Payee Mailing Address
Daytime Phone Number
If different than payee, please list the member’s/retiree’s name and Social Security number:
Member/Retiree Name (Last, First, Middle)
Retiree Social Security Number
I authorize and request:
The	Department	of	Retirement	Systems	(DRS)	to	transfer	the	full	amount	of	my	monthly	benefit	payment,	after
authorized	deductions,	to	the	designated	financial	institution	for	deposit.
The	designated	financial	institution	to	provide	information	to	DRS	regarding	address	changes	and	account
information, to ensure proper and timely processing of deposit transactions.
The	designated	financial	institution	to	refund	to	DRS	any	overpayments	to	my	account	made	subsequent	to	my	death
or payments made in error.
Signature of Payee
Section C: To	be	completed	by	financial	institution
We	agree	to	receive	and	deposit	sums	for	the	payee	named	above,	in	accordance	with	conditions	established	by	DRS.
We	further	agree	to	refund	to	DRS	any	payments	received,	in	accordance	to	this	agreement,	to	which	the	payee	was	not
entitled	by	reason	of	error	or	his/her	death,	if	sufficient	funds	exist	in	the	account.
Name of Financial Institution
c Checking c	Savings
Account Number to be Credited
Financial Institution Branch Mailing Address
Signature	of	Authorized	Financial	Institution	Officer
Section B: Payee’s	remittance	advice	statement
When	the	first	payment	has	been	deposited,	you	will	receive	a	remittance	statement	at	the	address	provided	in	Section	A.
For future statements, check only one:
c Send a st