PORAC RMT Direct Deposit Authorization Form

Administered by Benefit Programs Administration
1200 Wilshire Blvd, 5th Floor Los Angeles, CA 90017
Telephone: (877) 808-5994 Fax (562) 463-5894
Email: PORACRMT@bpabenefits.com
DIRECT DEPOSIT AUTHORIZATION FORM
Participant Name:*
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
Phone Number:*
Format: (000) 000-0000.
Email:*
example@example.com
Bank Name:*
Routing Number*
Account Number*
Routing Number:
Account Number:
CheckingSavings
As a participant in the PORAC Retiree Medical 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 PORAC 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 Proof of Account Holder*

Voided Check, Deposit Slip or Bank Letter / Statement
Cancelof
Signature*
Date

MonthDayYear
Date
Should be Empty:

DIRECT DEPOSIT AUTHORIZATION FORM