Mr. Theodore Wilder, Executive Secretary
Employees’ Retirement System
City Hall Building, Room 309
810 Union Street
Norfolk, Virginia 23510

Dear Sir:

I/We, the undersigned, hereby authorize and direct Theodore Wilder, Executive Secretary of the Employees’ Retirement System of the City of Norfolk to forward my monthly retirement check in the amount of $__________________ per month to the ______________________________________________ bank to be deposited in my account No. ________________________ and I/we further relieve the Employees’ Retirement System of any liability of the payment of said funds when said funds are transferred to the foregoing bank.

I/We further agree that all the parties who may withdraw funds from the foregoing account have signed this agreement, and if any change in the name of the account is made, we will notify Mr. Wilder immediately, and if any new person has access to this account, he/she will execute this or a similar agreement.

I/We further agree that in the event of the death of the retired member, any funds deposited to the account to which he/she is not entitled will be forthwith returned to the Employees’ Retirement System of the City of Norfolk, and I/We authorize the Bank to make such payment upon presentation by the City of any monies due it by virtue of having deposited money to the account after the death of the retired member.

_____________________________
Signature of retiree

______________________________

______________________________
Address

______________________________
Signature of any other parties

_____________________________
Date signed

For direct deposit, we need the following:

• A completed direct deposit sign-up form from your bank (many banks use the federal Standard Form 1199A), showing your correct account number, type of account (savings or checking), your bank’s ABA number, your bank’s correct mailing address and telephone number, and signed certification by you and joint payee (if any) and signed certification by the banking institution.

• A completed and signed form to the Retirement Secretary. This form and a self-addressed envelope are enclosed for your use.

Employees’ Retirement System
of the City of Norfolk
(757)664-4738