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Get PA PSRS-116 2015

Mail Center Authorization for Direct Deposit – Electronic Transfer of Monthly Benefit Instructions: The payee must complete this form. All entries must be typed or legibly printed in black ink. Payee Name Social Security No. Gender Date of Birth Former Last Name (only if used in this system) Which monthly pension account(s) does this affect? (check all appropriate box(es)) My retirement benefit Benefit I receive as a survivor annuitant Divorce Benefit Payee Agreement: I hereby authoriz.

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