AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT

I hereby authorize and request the Marblehead Retirement Board to forward my net pay to the following bank account:

Name*

Social Security #*

Joint Owner of Account (if applicable)

Social Security #

Bank Name*

Bank Routing #*

Bank Address*

Bank Account #*

Is the Account a:*

Checking Account

Savings Account

Please contact your bank if you need assistance in obtaining the above information.

Retiree Signature _____________________________________________

(Please sign after printing form)

Retiree Mailing Address*

Date

This form can be completed on-line, printed, signed and mailed or returned to:
Marblehead Retirement Board
Mary A. Alley Municipal Building
7 Widger Road
Marblehead, MA 01945

Please return this signed form with a copy of a VOIDED/CANCELLED CHECK or a SAVINGS WITHDRAWAL FORM to participate in the Direct Deposit of benefits being offered by the Marblehead Retirement Board.

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