Attach a Voided Check Here for Checking Account (Optional: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
In Part A, provide your personal details including your name, NDPERS Member ID, and the last four digits of your Social Security Number. Ensure accuracy as this information is crucial for identification.
Select the type of account you are authorizing for direct deposit: Member, Surviving Spouse, Beneficiary, or Alternate Payee. Specify the amount to be deposited; if left blank, 100% will be deposited by default.
In Part B, enter the Financial Institution Name and Routing Number. Clearly indicate whether it’s a checking or savings account and provide the corresponding account number.
For checking accounts, attach a voided check in the designated area. This step is optional but recommended for clarity.
Finally, sign and date the form to authorize NDPERS to process your request. Remember that electronic signatures are not accepted.

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