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PAROCHIAL EMPLOYEES RETIREMENT SYSTEM OF LOUISIANA THOMAS B. SIMS CFA. ADMINISTRATIVE DIRECTOR POB 14619 BATON ROUGE LA 70898-4619 TELEPHONES 225 928-1361 FAX 225 923-0933 APPLICATION/AUTHORIZATION FOR ELECTRONIC DEPOSIT OF RETIREMENT BENEFITS I hereby authorize the Parochial Employees Retirement System hereinafter called THE SYSTEM to initiate credit entries and to initiate if necessary debit entries and adjustments for any credit entries in error to my account select one Checking Savings indicated below and the depository bank named below hereinafter called DEPOSITORY to credit and/or debit the same to such account. DEPOSITORY BANK NAME CITY STATE ZIP CODE BANK TRANSIT/ABA MY ACCOUNT This authority is to remain in full force and effect until THE SYSTEM has received written notification from me of its termination in such time and in such a manner as to afford THE SYSTEM and the DEPOSITORY a reasonable opportunity to act on it. NAME SOCIAL SECURITY please print SIGNATURE DATE CONTACT NUMBERS RES RELATIVE VERY IMPORTANT ATTACH CHECK OR DEPOSIT SLIP HERE IN ORDER FOR THIS APPLICATION TO BE ACCEPTED AND TO CONFIRM ACCOUNT NUMBERS IT IS NECESSARY THAT WE HAVE THE FOLLOWING FOR CHECKING A VOIDED CHECK FROM YOUR PERSONAL CHECKBOOK WHICH MUST INCLUDE YOUR PREPRINTED PERSONAL INFORMATION IE ACCOUNT NAME ADDRESS FOR SAVINGS A DEPOSIT SLIP WITH PREPRINTED ACCOUNT INFORMATION* NECESSITY A POWER-OF-ATTORNEY IS REQUIRED ON ACCOUNTS WITH SIGNEES OTHER THAN THE MEMBER AND HIS/HER Please send with this application THESE FORMS WILL BE PROVIDED FOR YOUR CONVENIENCE UPON REQUEST. DEPOSITORY BANK NAME CITY STATE ZIP CODE BANK TRANSIT/ABA MY ACCOUNT This authority is to remain in full force and effect until THE SYSTEM has received written notification from me of its termination in such time and in such a manner as to afford THE SYSTEM and the DEPOSITORY a reasonable opportunity to act on it. NAME SOCIAL SECURITY please print SIGNATURE DATE CONTACT NUMBERS RES RELATIVE VERY IMPORTANT ATTACH CHECK OR DEPOSIT SLIP HERE IN ORDER FOR THIS APPLICATION TO BE ACCEPTED AND TO CONFIRM ACCOUNT NUMBERS IT IS NECESSARY THAT WE HAVE THE FOLLOWING FOR CHECKING A VOIDED CHECK FROM YOUR PERSONAL CHECKBOOK WHICH MUST INCLUDE YOUR PREPRINTED PERSONAL INFORMATION IE ACCOUNT NAME ADDRESS FOR SAVINGS A DEPOSIT SLIP WITH PREPRINTED ACCOUNT INFORMATION* NECESSITY A POWER-OF-ATTORNEY IS REQUIRED ON ACCOUNTS WITH SIGNEES OTHER THAN THE MEMBER AND HIS/HER Please send with this application THESE FORMS WILL BE PROVIDED FOR YOUR CONVENIENCE UPON REQUEST.

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