Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov
Direct Deposit Authorization
Form 21 – Revised 05/2/2022
Please print or type in black ink. A voided check or letter from your bank is required. Completed form should be mailed or faxed to PERS.
See bottom of form for contact information.
Benefit Recipient Information – PERS will automatically update the mailing address on file with the mailing address listed below.
First Name: _______________________________________ MI: ______ Last Name: ______________________________________________________
Mailing Address: ___________________________________________ City: _________________________ State: ______ Zip: _____________________
Social Security No.: _______________________________E-Mail: _______________________________________________________________________
Phone: _______________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Benefit Payments to Deposit – All payments selected for direct deposit will be fully and directly deposited to the bank account listed in Section 3. If you
are receiving multiple benefit payments each month (e.g., a survivor benefit payment and a retirement benefit payment or retirement benefit payments from two
separate plans) and would like for the separate payments directed to separate bank accounts, complete and submit a Form 21, Direct Deposit Authorization, for
each payment.
Public Employees’ Retirement System of Mississippi (PERS) .............................................................................................................. Retiree Beneficiary
Mississippi Highway Safety Patrol Retirement System (MHSPRS) ...................................................................................................... Retiree Beneficiary
Supplemental Legislative Retirement Plan (SLRP) ............................................................................................................................... Retiree Beneficiary
Municipal Retirement Systems (MRS) ................................................................................................................................................. Retiree Beneficiary
Bank Account Information – Direct deposit benefits are credited to bank accounts on the first banking day of the month that is not a weekend or
federal holiday. Allow one to two months after submitting this form for direct deposit to take effect. Benefit payments will be issued via check by mail
until direct deposit begins.
Check type of account to receive direct deposit. Check one per form.
Checking - Attach a voided, pre-printed check or direct deposit authorization form from banking institution. Starter checks will not be accepted.
Savings - Attach a savings account deposit slip or an official letter from banking institution that confirms type of account, name(s) on account,
account number, routing number, and bank representative or payee signature.
Applicant Authorization If an authorized representative signs this form, attach a copy of the durable power of attorney, conservatorship or
guardianship papers, or other legal documents as proof of authority to sign this form.
I hereby authorize PERS to directly deposit retirement benefits for the above-listed benefit recipient to the above-listed account.
Applicant’s Signature: _____________________________________________________________________ Date mm/dd/ccyy:______________________
Attach check or savings account deposit slip here.
If you selected “Checking” above, attach either a voided, pre-printed check or direct
deposit authorization form from banking institution. Starter checks will not be accepted.
If you selected “Savings” above, attach either a savings account deposit slip or an
official letter from banking institution that confirms type of account, name(s) on account,
account number, routing number, bank representative or payee signature.
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Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 www.pers.ms.gov
Notary Public Acknowledgement
Revised 01/15/2020
Please print or type in black ink. Complete this form and sign the corresponding form checked in Section 1 in the presence of the
notary. Once notarized and signed, attach corresponding form and submit both forms to PERS.
! Member/Retiree Information and Certification - Complete this section in the presence of the notary.
First Name: _______________________________________ MI: _______ Last Name: ______________________________________ Gender: ¨ M ¨ F
Social Security No.: ______________________ Birth Date mm/dd/ccyy: _______________ E-Mail: _____________________________________________
Mailing Address: ____________________________________________ City: ___________________________ State: _________ Zip: _______________
Phone: ________________________________ ¨ Cellular ¨ Home ¨ Work Phone: _______________________________ ¨ Cellular ¨ Home ¨ Work
Select the form that accompanies this Notary Public Acknowledgement.
¨ PERS Form 5, Member Refund Application (Required for inactive members only) ¨ PERS Form 5A, Member Waiver of Monthly Benefits
¨
PERS Form 5B, Spousal Waiver of Monthly Benefits (Requires member and spouse signatures*) ¨ PERS Form BW, Beneficiary Waiver
¨ PERS Form 21, Direct Deposit Authorization ¨ PERS Form 22, Waiver of Benefits
¨
Representative Payee Request ¨ Successor Information
I/We hereby certify that the above information is complete and accurate and that the form selected above and attached hereto has been completed by me/us,
the undersigned, with full knowledge and understanding of the purpose, intent, and outcome of any waivers, certifications, representations, and agreements
I/we made by signing said form.
Applicant’s Signature: ________________________________________________________________ Date mm/dd/ccyy: ____________________________
* Applicant’s Signature, if required: _____________________________________________________ Date mm/dd/ccyy: ____________________________
# Notary Acknowledgement
State of ___________________________
County of __________________________________
Personally appeared before me, the undersigned authority in and for the said county and state, on this
________ day of _________________________, 20_________, within my jurisdiction, the within named
________________________________________________________________, who acknowledged that
he/she/they executed the above and forgoing instrument and the attached corresponding form.
_____________________________________________ _______________________________
Notary Public My Commission Expires
Affix Notary Seal Below
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