wants to help you. Cayuga Lake National Bank CLNB CLNB FREE Cayuga Lake National Bank

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1 wants to help you. We ve got everything you need to get your banking moved from your current institution to Cayuga Lake National Bank and we are happy to help you Make the Move! A good place to start is to go through the enclosed Transaction Checklist to ensure that we do not miss anything along the way! After that, follow the bulleted outline below or ask one of our Customer Service Representatives for assistance! Open New CLNB Account(s). Fill out a Signature Card for each account you wish to open. Fill out the VISA Debit Card Application if you would like a debit card as well. Don t forget to take advantage of our products like estatements, Text Banking and CLmB (our mobile deposit app)! Enclosed you will find the Direct Deposit Authorization Change Form to fill out and give to your employer to change your direct deposit information. The ACH Authorization Change Form is to send to any of the ACH payments listed on your Transaction Checklist, requesting them to change your withdrawal information to your new CLNB account. Once you receive your new CLNB VISA debit card, be sure to contact any of the Debit Card tied items on your checklist to update them with the new number. Bill Pay items? We have you covered! As soon as your new account is opened, a Customer Service Representative will walk you through the Internet Banking enrollment ( In there, simply select the BillPay link on the left-hand side, select your account, and start adding your bills! You can choose any number of payment options to help you organize your life, not to mention they are all controlled by you, so you can change them when you need to without having to worry about envelopes, stamps or touch-tone menus and it s FREE! Once you are sure that all of your transactions have cleared or been transferred to Cayuga Lake National Bank, complete and send the Bank Account Closing Form to your current institution. Don t forget, that we are here to help you if you need us! We can t wait for you to be part of Cayuga Lake National Bank! We have been here for over 150 years and hope that you choose to join us for many more! Come see how being part of our family can be!

2 Transaction Checklist *Make sure you have all of your information for easy reference!* Payments Company/Address Account Number ACH Bill Pay Debit Card Amount Date Mortgage Auto Loan Personal Loan Insurance Credit Cards Gas/Electric Cable/Satelite Telephone Internet Water/Sewer Garbage Removal Health Club Investments Child Care Tuition/Studen Loans Newspaper/Magazine Charities/Donations Deposits Company/Address Account Number ACH Other Amount Date Payroll Retirement Social Security Investment Other

3 Account Number: Account Title: Account Type: Type of Account: Individual In-Trust-For (see below) Power of Attorney Joint (or the survivor) Convenience Only NYUTMA Other (Description): Signer #1 Signature: Social Security #: Mailing Address: Physical Address (if different): Phone #: D/O/B: Township: Occupation: Address: Employer: ID: Iss: Exp: Type of ID: OFAC ChexSystems Existing CLNB Customer Signer #2 Signature: Social Security #: Mailing Address: Physical Address (if different): Phone #: D/O/B: Township: Occupation: Address: Employer: ID: Iss: Exp: Type of ID: OFAC ChexSystems Existing CLNB Customer In-Trust-For (To Share and Share Alike) OR NYUTMA Successor: Beneficiary/Successor: D/O/B: Beneficiary: D/O.B: Beneficiary: D/O/B: Address: SS#: Address: SS#: Address: SS#:

4 I/We, the person(s) who signed the reverse, acknowledge that I/we have received and read your disclosure statement and agree to the terms and conditions governing this account. I/We agree that you are hereby authorized and empowered to charge this account with any loan or other indebtedness I or we owe to you. In order to make payment on each withdrawal, check or other order, you will require such authorized signatures as are appropriate, based on this and any other agreements or instructions I/we have on file with you. For Joint Accounts: I/we have received and read your Joint Account Notice, as applicable. Certification: Under penalties of perjury, I certifiy that (1)the number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), AND (2) I am not subject to backup withholding because: (a)i am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding and (3)I am a U.S. person (including a U.S. person (including a U.S. resident alien). Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN (see TIN disclosure). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signature Social Security Number Used For IRS Reporting Interviewer Date Info. Verified By Date Info. Input By Date Input Verified By Date

5 CL Cayuga Lake NB National Bank VISA Debit Card Application LAST NAME, FIRST NAME, MIDDLE INITIAL STREET ADDRESS APARTMENT NO./P.O. BOX NO. CITY, STATE, ZIP CODE SOCIAL SECURITY NUMBER ( ) - TELEPHONE ( ) - CELL PHONE (Initial Card is FREE! A replacement card is $5.00) TYPE ACCOUNT NUMBER CHECKING SAVINGS Signature(s )Required X Applicants Signature Date X Joint account holder (if applicant is under 18) Date (Bank Use Only) MAILED/FAXED TO CUST. DATE CSR INITIALS FORM ACCEPTED AT BANK DATE CSR INITIALS CARD ORDERED DATE OPER. INITIALS NEW CARD #

6 Cayuga Lake National Bank e-statement Agreement Definitions: For the purpose of this e-statement Agreement, I, you, your and user shall refer to the customer and we, us, our and bank shall refer to Cayuga Lake National Bank. Agreement: By selecting to receive your statements and disclosures; including but not limited to: Privacy, Fees & Service Charges, Regulation E, and Funds Availability, via electronic delivery; you are stating that you have the ability to access and retain the information using a device (ex. tablet, phone, PC, MacIntosh computer), with internet connection and software (ex. Adobe Reader, FoxIt Reader, Safari) that will open and a password protected.pdf type file to the address which you provide below. As with any password, it is your responsibility to protect it and contact us immediately should you feel that someone has gained access. It will be your responsibility to update us with your current address and any changes that would need to be made in the future. If s are returned as undeliverable and we do not receive updated information, paper statement delivery will resume. Enrollment will be complete when you reply to the entry affirming ability to receive and view the and its contents. By signing below, you agree to these terms and conditions stated above. You reserve the right to withdrawal consent at anytime by contacting us at (315) or 165 Cayuga Street, Union Springs, NY Paper Copies: You may request paper copies of your records if needed. By signing below, I agree to the above agreement to receive electronic statements (e-statements) and disclosures as mentioned above on the listed accounts. Customer Signature Date Account # Account Type Address ( for internal use) This above agreement has been sent/accepted by the following representative of Cayuga Lake National Bank as of the date below: Sent Initials: Date Sent: Employee Rec d Signature: Date Rec d:

7 165 Cayuga Street Union Springs, NY Main Street Aurora, NY SMS Banking Customer Name: Mobile Phone Number: ( ) - Mobile Carrier(must be one of the following: AT&T, Alltel Wireless, Boost Mobile, Cellular One, Cincinnati Bell, Nextel, Sprint, Verizon Wireless, T-Mobile, US Cellular, Virgin Mobile): Please write in your Account # s and remember what your reference (REF) to that Account # is: Max.# of Accounts (5) TOTAL REF Name Account # REF Name Account # CK1 SV1 CK2 SV2 CK3 SV3 CK4 SV4 CK5 SV5 Use of CLNB s Text Banking Service constitutes the customers agreement to these terms and conditions. I, the customer, agree to provide CLNB with a valid mobile number. I agree that CLNB may send text messages through my wireless provider. CLNB does not charge for the service, but I am responsible for all charges and fees associated with text messaging imposed by my wireless service provider. I understand that balances provided may not include recent or pending transactions that have not yet posted to my account. Transfers must be done and processed by 4pmEST to apply toward current day activity, after to be applied to the next business day. Notify CLNB immediately of any changes to/loss of your registered device. In case of unauthorized access to your device or service, you agree to contact us and cancel enrollment immediately. To cancel the Text Banking Service, send a text SUSPEND to at anytime or call a Customer Service Representative at (315) or I agree to indemnify, defend, and hold CLNB harmless from any third party claims, liability, damages or costs coming from my use of the service or from providing them with a phone number that is not mine. I agree that CLNB will not be liable for failed, delayed or misdirected delivery of, any information sent through the service; any errors in such information; any action I may or may not take in reliance on the information or service; or any disclosure of account information to third parties resulting from use of the service. I understand that Cayuga Lake National Bank is in no way responsible for any fees or charges that may arise from an SMS transaction that originates from my above listed cellular phone. Cayuga Lake National Bank has described the important security of having a password protected keypad lock turned on my phone at all times. I also understand that it is my responsibility to know what REF Name I have assigned to what deposit account number and that as with any savings accounts, Reg. D limitations apply (limit 6/mo). Signature: Date:

8 Drop completed form at any CLNB location, mail it to CLNB, 165 Cayuga Street, Union Springs, NY 13160, or fax it to A CLNB representative will follow-up and confirm your enrollment. Cayuga Lake mobile Bank User Service Agreement Name: Address: Cellphone Number: ( ) - Eligible Account(s) to be added: Address: SSN or TIN: User ID: Verified **Terms and Conditions will be displayed upon initial log in in order to access mobile app. There is a $.50/check fee. Please contact the bank with any questions.** Signature of Authority Party: Date: BANK ACKNOWLEDGEMENT Employee: Date: FOR BANK USE ONLY: Signature(s) Verified By Date Account(s) Eligible Yes, Reviewed by Date RDA Setup By Date Version July 2015

9 MOBILE DEPOSIT FREQUENTLY ASKED QUESTIONS What is Mobile Deposit? Mobile Deposit allows you to deposit checks using the camera on your mobile phone or tablet. To make a deposit using the CLmB Mobile App for the iphone or Android, follow these steps: 1. Log into the CLmb Mobile App on your mobile device using your credentials. 2. Click on Deposit. 3. Account Select the account for deposit. 4. Amount fill in the check amount. 5. Using your mobile device, click Check Front take a picture of the front of your check with your phone. 6. Click Check Back take a picture of the back of your check with your phone. 7. Click on Deposit Check. 8. You will receive a message on your mobile device that the deposit was made successfully (if you receive an error, address the problem and try again). 9. You will receive an confirmation of your deposit. 10. Be sure to verify the deposit to your account the following business day. What do I need in order to use CLmB? To use the CLmB service you must have the following: An open checking or savings account at CLNB. The most recent version of the CLmB app for iphone or Android from the Google Play Store or istore. o There is no charge to download the CLmB app on your mobile device. Who is eligible to use CLmB s service? Anyone with an active CLNB DDA account How do I request CLmB App Access? Contact one of our offices, complete the enrollment form. Do I need to use a deposit slip to make a deposit through CLmB? No deposit slip is required. You only need to endorse the back of your check, then take a picture of the front and back of the check being deposited. Should I endorse my check before taking a picture? Endorse your check before taking a picture as follows: For Deposit Only Your signature Account Number for deposit

10 What types of checks can I deposit with CLmB? Checks made payable to you and drawn on a bank within the United States are eligible for deposit. The following types of checks cannot be deposited using CLmB: Checks drawn on a financial institution located outside the United States Checks not payable in United States currency Savings Bonds Third Party Checks Returned or Re-deposited items Checks requiring two endorsements When will my funds be available to me from deposits made by CLmB? Deposits made prior to 3:00 p.m. EST Monday through Friday will be available to you by the end of business that day, 4pm EST. Deposits made on Saturdays, Sundays, or banking holidays will be available to you the following business day*. Are there limits for deposits made through CLmB? There are no dollar limits or quantity limits, however, Cayuga Lake National Bank reserves the right to impose applicable holds on funds if deemed necessary. See the Availability of Fund Disclosure. What do I do with a check after I deposit it through CLmB? Write Electronically Deposited on the face of the check. Verify that the deposit shows on your bank statement. Keep the deposited checks in a secure area for 30 days and then destroy. You may be asked to produce the original check if a problem occurs during the mobile deposit process, so it is important to retain deposited checks for 30 days before they are destroyed. What is the cost for CLmB? A per check charge of $.50 will apply. *Some checks are subject to hold. Please refer to CLNB s Funds Availability Policy. iphone is a trademark of Apple, Inc.

11 Direct Deposit Authorization Change Form Date: Your Company/Employer s Name: Please accept this letter as authorization to change the bank account information for direct deposits for: Your Name: Your Address: to Cayuga Lake National Bank, 165 Main Street, Union Springs, NY Cayuga Lake National Bank Routing Number: Cayuga Lake National Bank Account Number: Checking Savings Percent: Fixed Amount: Cayuga Lake National Bank Account Number: Checking Savings Percent: Fixed Amount: Should you have any questions regarding this transaction, please contact me at: ( ) -. Thank you for your time and assistance! Sincerely, Your Signature

12 ACH Withdrawal Change Authorization Form Date: To (Company/Biller): Please accept this letter as authorization to change the bank account information for my ACH withdrawals: Name: Address: Account Number (if applicable): to Cayuga Lake National Bank, 165 Cayuga Street, Union Springs, NY NEW Account Information: Cayuga Lake National Bank Routing Number: Cayuga Lake National Bank Account Number: Account Type: Checking Savings Should you have any questions regarding this transaction, please contact me at: ( ) -. Thank you for your time and assistance! Sincerely, Signature

13 Bank Account Closing Form Date: Please accept this as my authorization to close my account with your institution. Account Title (Name on the Account): Account Address: Checking Savings Certificate of Deposit Account Number: Please issue a Cashier s Check in the amount of the account balance, plus any accrued interest (if applicable). The check may be sent to the address above. Should you have any questions regarding this transaction, please contact me at: ( ) -. Thank you for your time and assistance! Sincerely, Signature

14 Sign-Up Form for Direct Deposit of Federal Benefit Payments FMS Form 1200 (July 2009) Previous versions obsolete OMB No You may also sign up online today at or call Go Direct toll free at 1 (800) (for social security, railroad retirement board, civil (non-military) retirement payments or VA only). DIRECTIONS Please read the information on page 2 before completing this form. You must complete boxes A, B, C, D, E and F. Only complete this form to sign up for direct deposit if you are an individual, or a representative payee of an individual, who receives checks for the following types of federal benefits: social security, supplemental security income, railroad retirement, civil (non-military) retirement, or VA (compensation or pension only). If you currently receive your payment by direct deposit you may not use this form. Please refer to page 2 for further instructions. A. FEDERAL BENEFIT RECIPIENT INFORMATION B. BANK OR CREDIT UNION INFORMATION (print name[s] and address exactly as they appear on your benefit check) NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY) DEPOSITOR ACCOUNT TITLE (name[s] on account) REPRESENTATIVE PAYEE? NAME OF REPRESENTATIVE PAYEE Yes if yes, enter No name at right ADDRESS (street, route, P.O. box, apartment number) ACCOUNT TYPE Checking Savings ** 9-DIGIT ROUTING NUMBER (see sample check below) CITY (or APO/FPO) STATE ZIP CODE ** ACCOUNT NUMBER (see sample check below; do not include check number) DAYTIME TELEPHONE NUMBER ( ) - SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY) ** You may also attach a voided personal check. If you are depositing into a savings account, you may need to contact your financial institution to obtain the routing and account numbers. SAMPLE CHECK (bottom left corner) ROUTING NUMBER ACCOUNT NUMBER CHECK NUMBER C. TYPE OF PAYMENT (check only one) You must complete a separate form for each type of federal payment. SOCIAL SECURITY SUPPLEMENTAL SECURITY INCOME For military, federal salary, veterans benefits or other federal payments not available through Go Direct, please contact the paying agency (see page 2 for a partial list of paying agencies). VA (COMP/PENSION ONLY) RAILROAD RETIREMENT (specify below) Annuity benefit Unemployment survivor benefit CIVIL (NON-MILITARY) RETIREMENT (specify below) Retirement annuity Survivor annuity D. IDENTIFICATION CLAIM NUMBER CHECK NUMBER (YOUR MOST RECENT PAYMENT) OR In order to process your request, either the claim number (found on documents from your paying agency) or the check number from your last payment (found in the upper right-hand corner of your Treasury check) must be entered at left. E. PAYMENT VERIFICATION You must also enter the amount of your last benefit payment. AMOUNT OF YOUR MOST RECENT PAYMENT $ F. CERTIFICATION I certify that I am entitled to receive the payment identified above, and that I have read and understand the back of this form. In signing this form, I authorize this payment to be sent to the financial institution named in Part B above, to be deposited into the account above. FOR JOINT ACCOUNT HOLDERS I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS on the back of this form. SIGNATURE DATE SIGNATURE DATE Be sure to complete all sections of this form. Otherwise, the form cannot be processed. Return the completed form to: Go Direct Processing Center U.S. Department of the Treasury P.O Box Dallas, TX This form is only to be used for switching from check payments to direct deposit of certain federal benefits listed in Box C. Use of this form for any other purposes will result in the form being rejected. Contact your paying agency to: Update your name or address Change your account information if you already receive your payment by direct deposit, or Sign up for direct deposit for military, federal salary, veterans benefits, or other federal payments not processed by Go Direct

15 PLEASE READ THIS CAREFULLY PRIVACY ACT NOTICE Your social security number and the other information requested will allow the federal government to make payments to you by direct deposit. This collection of information is authorized by Title 31 of the United States Code, Section 3332(g). Also, Executive Order 9397, November 22, 1943, authorizes the use of your social security number. Your social security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you from other recipients of federal payments. This information will be disclosed to the Department of the Treasury or another disbursing official to process federal payments to you by direct deposit. This information may also be disclosed to a court, congressional committee or another government agency as authorized or required by federal law and to your financial institution to verify receipt of your federal payments. Although providing the requested information is voluntary, your direct deposit payment may be delayed or Treasury may be unable to send it if you fail to provide the information. SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS If your account is a joint account and receives direct deposit benefit payments, you must inform the federal agency and the financial institution of the death of a beneficiary. Payments sent by direct deposit after the date of death or ineligibility of a beneficiary (except for salary payments) must be returned to the federal agency. The federal agency will then determine if the survivor is eligible for benefits. CANCELLATION Your payment will be sent by direct deposit until the federal agency that issues the payments is notified to cancel, such as in the case of death or legal incapacity of the person receiving the payment. Your financial institution may cancel your direct deposit authorization. Your financial institution is required to give you written notice 30 days in advance of the cancellation date. If this occurs, you must notify the federal agency that the direct deposit authorization was cancelled. Please contact your paying agency to: Update your name or address Change your account information if you already receive your payment by direct deposit, or Sign up for direct deposit for military, federal salary, veterans benefits, or other federal payments not processed by Go Direct Department of Veterans Affairs (877) (800) (800) TDD Social Security Administration (800) (800) TTY Railroad Retirement Board (Automated System) (877) (312) TTY Office of Personnel Management (888) (800) TDD BURDEN ESTIMATE STATEMENT The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD THIS ADDRESS SHOULD ONLY BE USED FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING. (2)

16 Office of the New York State Comptroller Thomas P. DiNapoli New York State and Local Retirement System Employees Retirement System Police and Fire Retirement System 110 State Street, Albany, New York Phone: or Fax: Web: Electronic Funds Transfer Direct Deposit Enrollment Application RS 6370L-3 (Internet Version) (Rev. 7/09) Date stamp: SECTION 1. TO BE REVIEWED AND CORRECTED BY PENSIONER Name: Soc. Sec. #: Retirement #: Address: Home Telephone: ( ) (Please Provide) Registration #: SECTION 2. TO BE COMPLETED BY PENSIONER I hereby request all future benefits which become payable to me from the New York State and Local Retirement System (NYSLRS) be transferred to my account via Electronic Funds Transfer (EFT) Direct Deposit to: Name of Financial Institution: Account Type: o Checking (attach voided check to Section 3, or have Section 3 completed by your financial institution) If your checks do not have your name imprinted on them, Section 3 must be completed by the financial institution. o Savings (Section 3 must be completed by financial institution.) NYSLRS is authorized to continue making such benefit payments to said financial institution or any of its successors until NYSLRS receives written notice from me to the contrary. I agree the NYSLRS shall have no liability or responsibility for loss occasioned by erroneous information supplied by myself, my duly authorized representative, or the financial institution. I expressly acknowledge and understand any payments made pursuant to this request will be strictly an accommodation made to me by NYSLRS. NYSLRS reserves the right to discontinue or decline to honor this EFT request without prior notice. I hereby authorize and direct the financial institution, on my behalf, my joint account holder, if any, and my estate to charge my account for amounts paid to which I was not entitled. I also agree, on behalf of myself, my joint account holder, if any, and my estate, that such amounts will be returned to the NYSLRS. By making this request, I hereby represent the account identified herein (and as may later be modified) is not a trust held for the benefit of another. Signature: Date: Signature of Joint Holder (If any): Date: SECTION 3. TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION IF DIRECTING FUNDS INTO A SAVINGS ACCOUNT OR IF A VOIDED CHECK IS NOT ATTACHED. THE ABOVE PENSIONER S NAME MUST APPEAR ON THE ACCOUNT. (Attach a preprinted voided check with your name imprinted on check here) Account Type: o Savings o Checking Transit/ABA Number (ACH Format) Depositor s Account Number (EFT Format) Name of Financial Institution: Address: Telephone: ( ) City: State: Zip Code: - I, as representative of the above named financial institution, agree to abide by the NACHA Rules and Regulations. Amounts paid to the account holder to which he/she is not entitled will be returned to NYSLRS. Liability shall be limited as prescribed in Section 4.7 of the NACHA Rules and Regulations. Bank Officer Signature: Title: Bank Officer (please print): PLEASE SEE BACK FOR INSTRUCTIONS

17 Enrollment Application PLEASE READ CAREFULLY The Electronic Funds Transfer Direct Deposit Enrollment Application must be signed by you and the joint account holder if any. If you are requesting direct deposit to a Checking Account, review Section 1 and make any necessary corrections, complete Section 2, then attach a voided check to Section 3. If a voided check is not attached to Section 3, or if your checks do not have your name imprinted on them, then Section 3 must be completed by your financial institution. Return the application to the New York State and Local Retirement System (NYSLRS). If requesting direct deposit to a Savings Account, Section 3 must be completed by your financial institution before you return the application to the NYSLRS. Pensioner and Joint Account Holder Authorization For Recovery of Funds Deposited in Error By signing this Electronic Funds Transfer Direct Deposit Enrollment Application, you, both for yourself and your estate, and each joint account holder, if any, consent to allow NYSLRS, through the designated financial institution, to debit your account in order to recover any NYSLRS benefits to which you were not entitled. This means of recovery shall not prevent the NYSLRS from utilizing any other lawful means to retrieve NYSLRS benefit payments to which you were not entitled. Changing Financial Institutions and/or Accounts You may change financial institutions and/or accounts by completing a new enrollment application. The new enrollment application, when processed, will cancel the enrollment at the previous financial institution or your prior account. You should, however, be aware that changing financial institutions and/or accounts could take up to 30 days to complete. We recommend that the old account not be closed until the first deposit is made to your new account or financial institution. Cancellation of Electronic Funds Transfer Direct Deposit To cancel this request, written notification from you must be received by the NYSLRS at least 30 days prior to the next payment date. The financial institution may terminate the electronic funds transfer direct deposit agreement with a written notice 30 days in advance of the cancellation date. The financial institution cannot cancel the authorization without notification to both you and NYSLRS. The New York State and Local Retirement System reserves the right to discontinue or cancel this electronic funds transfer direct deposit agreement at any time. Written notice will be provided to you. The completed applications should be returned to the following address: EFT/Pensioner Services New York State and Local Retirement System 110 State Street Albany, New York Questions or problems should be directed to the address above or you may call us at (518) or toll-free at

18 GRE-54 (1/11) NEW YORK STATE TEACHERS RETIREMENT SYSTEM 10 Corporate Woods Drive, Albany, NY Fax: (518) DIRECT DEPOSIT AUTHORIZATION AGREEMENT OFFICE SERVICES ONLY Please check this box if any of this direct deposit will go directly to a foreign bank or if the entire amount is forwarded from a domestic bank to a foreign bank. Please complete the information requested below and make a copy of this form for your records. EmplID # Social Security Number First Name MI Last Name Street Address Street Address City State Zip Code Phone Number ( ) If this is a change of address, please give effective date: / / Month Day Year Please indicate the type(s) of payments you are receiving from this system: Retiree Alternate payee under a Domestic Relations Order Beneficiary of a retiree ACCOUNT INFORMATION Education Law 524 states that a member s benefit is unassignable to an account that is in the title of a Trust. The following bank information is or will be used to transmit your retirement payments directly to your bank account. The bank ABA # / Routing # is usually the first 9 digits on the bottom of your check, or this number can be obtained by contacting your bank. If you have any questions regarding your ABA # or account number, contact your financial institution. BANK NAME BANK TELEPHONE NUMBER ( ) BANK ABA # / ROUTING # (ACH format - 9 digits) ACCOUNT # ACCOUNT TYPE (Please check one) CHECKING SAVINGS Note: Deposits can be made to money market accounts I authorize NYSTRS to automatically deposit any benefit payable to me in the foregoing account, or in any future account hereafter communicated by me to NYSTRS in writing, which future account(s) shall be subject to the terms of this Direct Deposit Agreement. I understand that I may cancel this authorization by submitting written notification to NYSTRS. I understand NYSTRS may cease to honor this authorization or may change the terms upon notice to me. I also understand that NYSTRS shall not be responsible for any delay resulting from inaccurate information supplied to NYSTRS. I understand I am entitled to my benefit payment until the date of my death. I authorize NYSTRS to recover any overpayment from my financial institution. Month Day Year SIGNATURE: / /