Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Instructions for Authorization for Deposit of Pension Payments Form To sign up for direct deposit in United States banks only: • Fill out numbers 1 through 7 of the attached form, check whether you want your benefits deposited (into checking or savings) and complete the following: • For Checking: Attach a voided check from your checking account with your name and address preprinted on it; or • For Savings: Attach a voided deposit slip from your savings account with your name and address preprinted on it; or • Have your financial institution complete the bottom half of the Authorization for Deposit of Pension Payments. • Send the ORIGINAL copy to the address above or fax it to (360) 902-6455. • Make a COPY for your records. • You must sign and date the Authorization for Deposit of Pension Payments form. Incomplete forms will be returned for completion. • A legal power of attorney (POA), can complete the form for you. We must have a copy of the POA document on file OR A notarized copy of it must be sent with the Authorization for Deposit of Pension Payments. General information: • It may take up to 30 days for the direct deposit to go into effect. • Call (360) 902-5119 if you have questions. F242-174-000 Auth for Deposit of Pension Payment 02-2011 American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 FAX (360) 902-6455 AUTHORIZATION FOR DEPOSIT OF PENSION PAYMENTS Recipient: Please complete 1-7. 1. Name of pension payment recipient Claim Number Folio Number I authorize and request the Washington State Department of Labor and Industries to transfer the amount of my pension payment to the designated financial institution 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 Phone number ( ) 4. Recipient’s phone number ( ) 3. Recipient’s Social Security Number (for ID only) Check box if this is an address change (If checked, please fill in new address below) 5. Mailing address of recipient 6. Date City State ZIP 7. Signature of recipient (Required) Please provide one of the following: For Checking Attach a voided check preprinted with your name and address. For Savings Attach a voided deposit slip preprinted with your name and address. Financial Institution To complete items below: Incomplete forms will be returned for completion. Financial institution: Please complete. Name of financial institution Branch Date Financial institution officer’s title Phone number ( ) Name of financial institution officer Deposit or account number to be credited ROUTING # F242-174-000 Auth for Deposit of Pension Payment 02-2011 Signature of financial institution officer ACCOUNT # American LegalNet, Inc. www.FormsWorkFlow.com