Pension Direct Deposit

Bank Name: *

Bank Address: *

Please include the full address of your Bank.

Bank Routing Number: *

Account Type: *

Checking

Savings

Account Number: *

Bank Phone Number: *

Participant's Signature: *

Date: *

Participant's Soc. Security #: *

Do Not Use Dashes

Fox Valley & Vicinity Laborers Pension Fund

Section V.

1. Participant Authorization

Direct Deposit Authorization

I authorize the Administrative Office to deposit my pension benefit check directly into my account as follows:

By typing my signature in the box below, I acknowledge that I am digitally signing this authorization form.

Health, Welfare and Pension Funds