Massachusetts Direct Deposit Form 1
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AUTHORIZATION FOR

T H E C O M M O N W E A LT H O F M A S S A C H U S E T T S

State Board of Retirement
ONE WINTER STREET, 8TH FL, BOSTON, MA

DIRECT DEPOSIT
OF RETIREMENT BENEFIT

02108

SECTION A (required)
Name:
Address:
City:

State:

Zip:

Phone:

Email:

SS#

Member ID (if known):

SECTION B (required)
Name of Financial Institution:
All Names on Account:
Routing #:
Depositor Account #:
Please Check Appropriate Box:

Savings Account

Checking Account, voided check attached

Are you receiving direct deposit in this account as an active employee of the commonwealth?

Yes

No

N/A

IF BEING DEPOSITED INTO A CHECKING ACCOUNT PLEASE INCLUDE A VOIDED CHECK
Check box if any of the above direct deposit will go directly to a foreign bank or if the entire amount is forwarded from a
domestic bank to a foreign bank.

PLEASE SIGN BELOW (required)
“I, ___________________________________________hereby authorize the State Treasurer to deposit my retirement
benefit into my account at th