Illinois Direct Deposit Form 3Illinois Direct Deposit Form 3
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Application for Direct Deposit
IMRF Form 1199 (Rev. 07/07)

This form should be completed by the Benefit Recipient (IMRF member or person
receiving the IMRF benefit payment).
Name

Social Security Number

_____________ — ________ — _____________

Address (Number, Street)

City

Is this a new address?

Telephone Number

Yes

No

(

State

Zip

)

Account Information—Important: The name of the person who will receive the IMRF
benefit payments must be on this account. Please provide the information requested
below. If you are unsure of any of the requested information, contact the financial
institution where you have your account. (See the back of this form for more information.)
Name of Financial Institution

Branch Telephone Number

(

Branch Address (Number, Street)

City

)
State

Zip

Account Number

Financial Institution Routing Number

Type of Account

Checking

Savings

I authorize and request the Illinois Municipal Retirement Fund to direct IMRF recurri