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Genesee County Employees’ Retirement System

1101 Beach Street               Flint, Michigan  48502-1453


(810) 257-2626 or (800) 949-2627         Fax:    (810) 257-3560

 

Authorization Agreement for Automatic Deposits (ACH Credits)


I hereby authorize GENESEE COUNTY EMPLOYEES’ RETIREMENT SYSTEM (GCERS) to make deposits from time to time in the account identified below at:

 


(Name of your Bank or Credit Union)      (Telephone Number)

(Depository Financial Institution, which means your bank or credit union, hereinafter referred to as DFI) and authorize the DFI to accept these deposits.  Adjusting entries to correct errors are also authorized.  It is agreed that these deposits and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association.  This authorization will remain in effect until written notice of termination is given to the Company.  I acknowledge that I have kept a filled-in copy of this form for my records.

Name of DFI

(Bank or Credit Union)              

                              DFI’s Routing &

Transit Number                                                    

Account Number to Credit      

Type of Account

(check one)

 

                                            

                             

  Checking

  Savings

 

PLEASE PRINT

Name              

Address                       

City                 

State               

Zip Code

 

 

 

 

 

 

SIGN HERE                 

Date                

Social Security Number

 

 

 

 

                                    STAPLE YOUR VOIDED CHECK OR DEPOSIT SLIP HERE                         

RETURN THIS FORM TO THE GCERS OFFICE (address listed above)