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2. 
3. Electronic Funds Transfer Authorization

   City of Roseville Police & Fire Retirement System

   Sharon Maas
   586-447-4651

5. FOREIGN FINANCIAL INSTITUTION DECLARATION
7. DECLARATION-U.S. Law requires that the following information be obtained for all Direct Deposit (ACH) transactions.*

   Will the pension payment that is made via direct deposit pursuant to this Authorization be forwarded across the U.S. Border to a foreign financial institution thought the ACH network on the same day that it is deposited into your account?

   1. NO (Please proceed and complete the remainder of the form)
   2. YES (Please complete the Foreign Financial Institution Information before completing the rest of the form)
9. Foreign Financial Institution Name*
11. Foreign Financial Institution Identification Number*
13. Foreign Financial Institution Address*
17. PERSONAL INFORMATION
19. Name
20. Email Address*
22. Address
24. City
25. State
26. Zip Code
28. Phone Number
30. Name of Plan Sponsor:

    City of Roseville #089686

34. DEPOSIT INFORMATION
36. DEPOSIT #1 U.S. Financial Institution Name*
38. DEPOSIT #1 U.S. Financial Institution Address*
40. DEPOSIT #1 ACH Routing/Transit Number*
41. DEPOSIT #1 Account Type*

    1. Checking
    2. Savings
42. DEPOSIT #1 Account Number*
44. DEPOSIT #1 Amount

    If Pension is being deposited into only one account, please leave this field blank.

48. DEPOSIT #2 U.S. Financial Institution Name*

    Complete ONLY if you wish to have your Pension deposited into two different accounts each month

50. DEPOSIT #2 U.S. Financial Institution Address*
52. DEPOSIT #2 ACH Routing/Transit Number*
53. DEPOSIT #2 Account Type*

    1. Checking
    2. Savings
54. DEPOSIT #2 Account Number*
56. DEPOSIT #2 Amount
60. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    I certify that the information I have provided on this Electronic Transfer Authorization Form is correct and complete.  I understand that this Authorization will remain in effect until I submit written authorization to cancel or change the information contained herein.  I authorize and direct Comerica Bank to make the monthly pension payment payable to me under the CITY OF ROSEVILLE POLICE & FIRE RETIREMENT SYSTEM plan via the Automated Clearing House (ACH) system to the financial institution(s) and account number(s) named herein.

    1. I agree.
62. Electronic Signature*
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field