Form DA (Rev 1/26/2016) State of Delaware New Address
Pensioner’s Direct Deposit Authorization Form
Name
Social Security #
Employee ID
Address
City, State, ZIP+4
This form will override all previous forms. Please list ALL accounts where you wish to have monies deposited.
We no longer require verification in the form of a voided check or bank statement. However, please be aware that
YOU
ARE RESPONSIBLE for ensuring that the routing and account numbers on this form are correct. Please contact
your
bank to confirm routing/account numbers if you are
unsure.
INCORRECT ROUTING AND/OR ACCOUNT NUMBERS WILL RESULT IN YOUR DIRECT DEPOSIT
BEING
DELAYED UNTIL THE NEXT SCHEDULED PENSION
PAYMENT.
To have your net Pension amount go to ONE account or to have the majority of your monthly Pension amount go to a primary
account (with specific dollar amounts going to additional accounts listed below), complete the following:
Deposit Net Monthly Pension Routing # Account # CHECK ACCOUNT TYPE:
Amount
into
this
account.
Checking Savings
OR
Bank
Name
Use this account as primary
with additional monies going Bank Address
to accounts listed below.
If you are using this form to change an existing direct deposit to a primary account and wish to have ALL
other additional deposits (i.e. savings account deposits and/or credit union deposits) remain the same,
Please check
one
Continue additional deposits OR Stop additional deposits and deposit all monies into the above account
To have a specific dollar amount go to additional banks or credit unions, complete as many of the following as necessary:
Deposit the Following $ Amount Routing # Account # CHECK ACCOUNT
TYPE:
Checking Savings
Bank Name
Bank
Address
Deposit the Following $ Amount Routing # Account # CHECK ACCOUNT
TYPE:
Checking Savings
Bank Name
Bank
Address
I understand that my monthly benefit amount will be direct deposited to the account(s) designated above so that the funds are
available to me on the last working day of each month.
Signature of Pensioner or Power of Attorney Telephone Number Date
Return form to the Office of Pensions, McArdle Building, 860 Silver Lake Blvd., Suite 1, Dover, DE 19904-2402 or
fax completed form to (302) 739-6129. If you have any questions, call the Pension Office at (302) 739-4208 or (800) 722-7300.
NOTE: If you move and the “Direct Deposit Advisory Notice” or other mailings are returned undeliverable by the Post Office,
your electronic funds transfer authorization will be terminated and the funds held until a signed change of address has been
received by the Pension Office.
