(Please Print)
_____________________________________________________________________
Name of retiree/person receiving payment
_____________________________________________________________________
Mailing Address
_____________________________________________________________________
City/Town State Zip Code
Please deposit my monthly pension check from the Town of Wellesley Contributory Retirement System into my:
___Checking or Now ____Savings _____Credit Union ____Credit Union
Checking Savings
Account Number ______________________________________________________
Routing # ____________________________________________________________
PLEASE ATTACH A VOIDED CHECK--THANK YOU
Bank/Credit Union _____________________________________________________
____________________________________________________________________
City/Town State Zip Code
I hereby authorize the Town of Wellesley Contributory Retirement System to deposit my monthly pension check to my account at the financial institution named above. Also, the Town of Wellesley Contributory Retirement System is authorized to adjust any over deposit made to my account by the system. I will not hold the financial institution named above for any erroneous deposits or adjustments made by the System named.
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Signature
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Date
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