Brockton Retirement Board

15 Christy’s Drive, Suite 2

Brockton, MA  02301-1813

Brockret@comcast.net

Tel: 508-580-7847

Fax: 508-559-0559

 

DIRECT DEPOSIT AUTHORIZATION FORM

 

SSN__________________

 

Name

Last __________________________First______________________Middle_____________

 

Mailing address

Number and street___________________________________________________________

 

City, state and ZIP___________________________________________________________

 

Phone number (       ) ____________________

 

FOR CHECKING ACCOUNTS YOU MUST ATTACH A “VOIDED” CHECK

 

Financial institution__________________________________________________________

 

Checking account number_____________________________________________________

               OR

Savings account number_______________________________________________________

 

Bank routing number__________________________________________________________

 

Retiree Signature __________________________________Date________________________

 

Please note: Whenever there is a change in your account or if you are opening a new account, your first check will be mailed to your home and the following month your check will be direct deposited.