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Get TX TCDRS-70 2009-2024

YOUR INFORMATION FORMER EMPLOYER NAME ACCOUNT NUMBER MIDDLE NAME MAILING ADDRESS LAST NAME SSN CITY FIRST NAME STATE HOME PHONE NUMBER ZIP CODE MOBILE PHONE NUMBER BANKING INFORMATION CHECKING FINANCIAL INSTITUTION ROUTING NUMBER SAVINGS YOUR AUTHORIZATION For the account referenced above I authorize the Texas County District Retirement System TCDRS to deposit my monthly benefit payments into my bank account. TCDRS-70 REV. 08/2009 PAGE 1 OF 1 Direct Deposit Authorization NOTICE This form must be received by the 15th of the month for your monthly benefit payment to be directly deposited into your bank account by the end of the month. I also authorize TCDRS to make adjustments to my account to correct any transactions made in error. This authority shall remain in effect until I notify TCDRS to discontinue this payment method. I have requested the Texas County District Retirement System to directly deposit my benefit payments by electronic transfer to the above referenced account and I hereby authorize the financial institution named above to disclose to the Texas County District Retirement System at any time my address and contact information and to disclose the names and addresses of all joint owners signatories beneficiaries or other persons associated with the above referenced account if I pass away. A photocopy of this signed form shall be sufficient authorization for such disclosure. X SIGNATURE DATE Print Form Reset Form REQUIRED FIELDS Any corrections or whiteouts must be initialed* TCDRS PO Box 2034 Austin TX 78768-2034 512 328-8889 800-823-7782 Fax 512 328-8887 www. I also authorize TCDRS to make adjustments to my account to correct any transactions made in error. This authority shall remain in effect until I notify TCDRS to discontinue this payment method. I have requested the Texas County District Retirement System to directly deposit my benefit payments by electronic transfer to the above referenced account and I hereby authorize the financial institution named above to disclose to the Texas County District Retirement System at any time my address and contact information and to disclose the names and addresses of all joint owners signatories beneficiaries or other persons associated with the above referenced account if I pass away. This authority shall remain in effect until I notify TCDRS to discontinue this payment method. I have requested the Texas County District Retirement System to directly deposit my benefit payments by electronic transfer to the above referenced account and I hereby authorize the financial institution named above to disclose to the Texas County District Retirement System at any time my address and contact information and to disclose the names and addresses of all joint owners signatories beneficiaries or other persons associated with the above referenced account if I pass away. A photocopy of this signed form shall be sufficient authorization for such disclosure. X SIGNATURE DATE Print Form Reset Form REQUIRED FIELDS Any corrections or whiteouts must be initialed* TCDRS PO Box 2034 Austin TX 78768-2034 512 328-8889 800-823-7782 Fax 512 328-8887 www. .

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