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my|CalPERS 1362
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
REFUND DIRECT DEPOSIT AUTHORIZATION
Section 1 Information About You
A separate form must
be completed for
each type of
retirement benefit to
be sent by Direct
Deposit.
Section 2
If you are authorizing
your payment to your
savings account or do
not have pre-printed,
personalized checks,
you must have your
financial institution
complete this section.
* Trust Accounts
You will receive a confirmation letter with the effective date once CalPERS has
processed this completed form. You can review your statement online or receive
it by mail from the California State Controller’s Office. In order to receive
important information about benefits, payees should keep CalPERS informed of
any address changes.
Name (First Name, Middle Initial, Last Name) CalPERS ID Number
Address Daytime Phone
City State ZIP
Information About Your Account
Checking Savings Individual Joint (If so Trust Account*
Complete
Section 3)
Routing Number (nine digits) Account Number
Please use tape to attach your voided, pre-printed personalized check. (Do
not staple or paper clip. No deposit slips.)
Name of Financial Institution Branch Phone
You will need to
complete a CalPERS
Address
trust form, which can
be obtained by
contacting CalPERS
City State ZIP
You confirm the identity of the above-named payee and the account number. As
a representative of the above named financial institution, you certify the financial
institution agrees to receive and deposit the payment identified above.
Signature of Representative Print Representative's Name Date (mm/dd/yyyy)
