Free F242-174-000 Authorization for Deposit of Payments - Washington

Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281

AUTHORIZATION FOR DEPOSIT OF PAYMENTS
Claim Number Folio Number

Recipient: Please complete 1-7.
1. Name of pension payment recipient

I authorize and request the Washington State Department of Labor and Industries to transfer the amount of my pension payment to the designated financial institutions for deposit in my: Checking Account Savings Account This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notices. This authorization will remain in effect until canceled by written request from me. I understand that the financial institution and the Department of Labor and Industries have the right to cancel this agreement by notice to me. I further authorize the Department of Labor and Industries to initiate adjustments to my account for deposits made in error.
2. Name of financial institution 3. Recipient's Social Security Number (for ID only) 5. Mailing address of recipient City 6. Date 7. Signature of recipient Phone number ( ) 4. Recipient's phone number ( ) State ZIP

Check if this is an address change

Please provide one of the following: Attach a voided check preprinted for Checking account only from your bank with your name and address.

Attach a voided deposit slip preprinted for Savings account only with your name and address

Financial institution to complete items below:

Financial institution: Please complete.
Name of financial institution Date Name of financial institution officer Deposit or account number to be credited Phone number ( ) Branch Financial institution officer's title Signature of financial institution officer

:

BK

TR

RT

#

:

ACCOUNT #

ORIGINAL ­ Pension Benefits
F242-174-000 auth for deposit of payment 02-2009

COPY ­ Recipient

PLEASE PRINT ON WHITE PAPER

RESET