Louisiana Direct Deposit Form 1Louisiana Direct Deposit Form 1
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Form 4-05
R082010

ERBER11

DO NOT FAX FORM
PRINT ALL INFORMATION
www.lasersonline.org

P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)

Authorization for Direct Deposit
Member's First Name

Middle Name

Last Name

Today's Date

Name of Payee

Social Security Number

Name of Joint Account Holder (if applicable)

Social Security Number

Payee's Mailing Address

Daytime Area Code/Phone Number

City

Social Security Number

Date of Retirement (if applicable)

State

Evening Area Code/Phone Number

Zip Code

E-mail Address

SECTION 1: ACCOUNT INFORMATION
Check at least one of the following options:
Name and Address of Financial Institution

Monthly Retirement Benefit
Type of Account:

DROP/IBO Withdrawal
Routing Number

Depositor Account Number

Checking
Savings

SECTION 2: PAYEE AND JOINT ACCOUNT HOLDER'S SIGNATURE
I hereby authorize the Louisiana State Employees' Retirement System (LASERS) to direct the net amount of my m