GERS Form 1002 
 
 
RETIREE DIRECT DEPOSIT 
ENROLLMENT FORM 
 
Name: ____________________________________________________  SSN:  __________________________________ 
 
Address: __________________________________________________  Home Phone:  ___________________________ 
 
I do hereby authorize the Government Employees’ Retirement System (hereinafter GERS) to directly deposit my semi-
monthly net pay to the following account(s): 
 
You may choose up to three accounts: 
 
1. Bank Name:  ____________________________________________________  Phone:  (        )____________________ 
 
Address:  _______________________________________________________________________________________ 
                          Street                                             City                                           State                                     Zip           
 
Account No.:  ___________________________________________ Routing Transit #:  ________________________ 
 
 Checking    
 Saving   
 
I wish to deposit $ __________________._____ or 
 Entire Net Amount 
 
2.  Bank Name:  ____________________________________________________  Phone:  (        )____________________ 
 
Address:  _______________________________________________________________________________________ 
                          Street                                             City                                           State                                     Zip           
 
Account No.:  ___________________________________________ Routing Transit #:  ________________________ 
 
 Checking    
 Saving   
 
I wish to deposit $ __________________._____ or 
 Entire Net Amount 
 
3. Bank Name:  ____________________________________________________  Phone:  (        )____________________ 
 
Address:  _______________________________________________________________________________________ 
                          Street                                             City                                           State                                     Zip           
 
Account No.:  ___________________________________________ Routing Transit #:  ________________________ 
 
 Checking    
 Saving   
 
I wish to deposit $ __________________._____ or 
 Entire Net Amount 
 
I understand that this authorization may be terminated by me upon two (2) weeks notice in writing to the Government 
Employees’ Retirement System. I further understand that as a Direct Payroll Deposit Participant.  I will receive a voided 
check in lieu of a Paycheck if I choose not to have a remaining amount sent directly to me. Residual amounts should be $50 
or more for mailing. Anything less will be automatically deposited to your account.  
 
 
 
 
 
 
 
Signature:  _______________________________________________________________  Date: ____________________ 
Please attach a voided copy of your personal check or official savings account documentation and allow two periods for 
processing. 
GOVERNMENT EMPLOYEES’ RETIREMENT SYSTEM
GOVERNMENT EMPLOYEES’ RETIREMENT SYSTEMGOVERNMENT EMPLOYEES’ RETIREMENT SYSTEM
 
Notes:  The GERS will be operating as agent for the purpose of Direct Payroll Deposit not as an agent of the depository 
institution(s) named above.  The GERS therefore does not accept responsibility for any negligence on the part of said 
depository institution.  If any payments made are dated after the last day of the month in which my death occurs, I hereby 
authorize and direct the said financial institution on my behalf and on my behalf of my executors or administrators, to 
refund any such payments to the Government Employees’ Retirement System and to charge the same to my account. 
Form Reviewed by: ________________________________________________________  Date:  ____________________ 
(For GERS Use Only)