MICHIGAN UPPER PENINSULA

INTERNATIONAL BROTHERHOOD OF ELECTRICAL WORKERS

PENSION PLAN

DIRECT DEPOSIT AUTHORIZATION FORM

Section A – to be completed by applicant

I hereby authorize the Michigan U.P. IBEW Pension Plan to initiate credit entries to my account listed below, in the financial institution shown.  In the event a credit is made to my account in error, I authorize Michigan U.P. IBEW Pension Plan to make a correcting entry, provided I am notified of the adjustment. This authorization is to remain in effect until Michigan U.P. IBEW Pension Plan has received written notification from me assigning a new financial institution.

Account Number:_______________________________________________________________

Is this a checking  _________ or savings  ___________  account?

Financial institution name/address:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signature of Applicant___________________________________________________________

Date__________________________________

(_____) _______________________________    ______________________________________

                  (Telephone Number)                                                                          (Social Security Number)

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Section B – to be completed by the financial institution

Account Number:_______________________________________________________________

ABA (Routing) Number:______________________________________

Name and telephone number of representative to whom inquires can be made:

_______________________________________________________ (_____) _______________