Fill and Sign the Carer Payment Allowance Medical Report Form

Direct Deposit/Automatic Payment Information Form Three Easy Steps To Set Up Direct Deposit or Automatic Payment(s) Step 1. Gather Account Information You must provide your information about the account where the money will be deposited or withdrawn. Routing Number (ABA) 9 digits For Direct Deposit and/or Automatic Payment through Checking Account 325183738 MEMBER YVCU Accounts Opened Prior to 10/1/11: PLE 325183796 Type of Account (Check one) Checking Account SAM 9 Numbers Routing Number For Direct Deposit and/or Automatic Payment through Savings ACCOUNT CK E CH For your savings account number, look at your Solarity statement or your Solarity membership card. Maximum 8 digits. 14 Numbers Acount Number Account Number - 14 digits (Do not include check number) Savings Account _ Step 2. Contact Your Employer or Payor Use the table below to find the correct contact to learn if your payor offers direct deposit services and to provide your account information. Your payor may need you to complete a form or provide a voided check to process your request. Type of Direct Deposit Change Enrollment New Enrollment (To change your paper checks to electronic deposits) • • • Salary and wages Pension Dividend/Investment Income Contact your employer or payor directly Contact your employer or payor directly • • Social Security (SSA) Supplemental Security Income (SSI) Call 1-800-772-1213 www.godirect.org or call 1-800-333-1795 • Railroad Retirement Call 1-800-808-0772 www.godirect.org or call 1-800-333-1795 • Civil Sevrice Retirement Call 1-888-767-6738 www.godirect.org or call 1-800-333-1795 • Veterans Compensation Call 1-877-838-2778 Call 1-877-838-2778 • Other Federal Agencies Contact the agency directly or call GO DIRCECT at 1-800-333-1795 to get the telephone numbers for many federal agencies. Contact the agency directly or call GO DIRCECT at 1-800-333-1795 to get the telephone numbers for many federal agencies. Step 3. Monitor Your Account For direct deposit, it can take one to two months for a payor to process your request and to begin receiving electronic deposits. Questions? Contact Solarity at 509-248-1720 or toll-free at 1-800-347-9222 DirectDep-AutoPay 11/2011