IAFF MERP DIRECT DEPOSIT AUTHORIZATION FORM

DIRECT DEPOSIT AUTHORIZATION FORM
Participant / Member Name*
Date of Birth*

MonthDayYear
Social Security Number*
Phone Number*
Email*
example@example.com
Bank Name*
Routing Number*
Account Number*
Routing Number
Account Number
Account Type*

CheckingSavings
As a participant in the IAFF MERP Trust (the “Trust”), you will be entitled to receive reimbursement benefits, as explained in the “Medical Expense Reimbursement Plan” of the Trust. The Trust Office offers direct deposit of your reimbursement benefit payments into your personal bank account. If you do not select direct deposit, you will receive your reimbursement benefit payments in the form of a check To proceed with setting up direct deposit for your IAFF MERP Trust reimbursement benefits, you’ll need to provide proof that you are an account holder and confirm your routing and account number. This is typically done by submitting one of the following:
1. A voided check – This shows your name, routing number, and account number.
2. A deposit slip – This also contains your bank details, though not all slips include your name.
3. A bank letter or statement – As long as it includes your name, routing number, and account number.
Upload Image of Voided Check / Deposit Slip / Bank Letter / Statement*

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By my signature, I authorize the Trust Office to directly deposit my benefit payments into my bank account held at the bank named below. This authorization will remain in effect until I notify the Trust Office in writing.
Signature*

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Date

MonthDayYear
Fund ID
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