HPR Authorization Agreement for Electronic Pension Benefit Deposit

Heating, Piping and Refrigeration Pension Fund

Mailing Address: PO Box 21427 Eagan, MN 55121 Phone: (410) 444-3756 or (800) 618-2879 • Fax: (240) 303-2484 • Website: HPRBenefitFunds.com

Administered by Welfare & Pension Administration Service, Inc.

AUTHORIZATION AGREEMENT FOR ELECTRONIC PENSION DEPOSIT
I hereby authorize the Heating, Piping and Refrigeration Pension Fund to make Pension benefit deposits to my bank account. This authorization is to remain in full force and effect until the Administration Office receives written notice from me instructing them otherwise. I understand that it can take up to (30) thirty days to make bank and/or account number changes and/or to discontinue my electronic deposit.

In the event an amount should be credited in error to my account, including, but not limited to, by reason of my death prior to the date on which any payment shall become due, I authorize the Trust Fund to direct the Depository to make the appropriate debit adjustment.
Member Name*

First NameMiddle InitialLast Name
Form Name
Social Security Number*
Home Street Address*
City*
City Separator
State*
Zip Code*
Form Address Field
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Name of Bank / Financial Organization
Bank's Phone Number*
Please enter a valid phone number.
Bank's Mailing Address*
Street Separator
City*
City Separator
State*
State Separator
Zip Code*
Form 1 Address Field
Routing Number (9 Digits)*
Form Routing Number
Account Number*
Form Account Number
Account Type*

SavingsChecking
Member Signature*

Clear
Date

MonthDayYear

PLEASE CONTACT YOUR FINANCIAL INSTITUTION FOR THE NECESSARY NUMBERS REQUESTED AND ENCLOSE EITHER A BANK VERIFICATION LETTER OR A VOIDED CHECK

Upload Bank Verification Letter OR a Voided Check*

Cancelof
To ensure that your retirement checks are received in a timely manner, and your retirement records are up to date, a Continuance Form will be mailed to you annually. If the Continuance Form is not returned, your retirement checks will be withheld until the Administration Office has received your completed form.
Fund ID
Should be Empty:

Heating, Piping and Refrigeration Pension Fund

AUTHORIZATION AGREEMENT FOR ELECTRONIC PENSION DEPOSIT