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International Painters and Allied Trades
Industry Pension Fund
7234 Parkway Drive“ Hanover, MD 21076
& ve Telephone: (410) 564-5500 - Toll Free: (800) 554-2479 - Fax: (866) 656-4160
,
.ension@iupat.org / www.iupatpension.or
pe pe pat.org, pat eB
TU eeu ar ica
This form authorizes the International Painters and Alied Trades Industry Pension Fund (the "Fund') to send payments to the
Designated account. This document remains n effect until canceled in writing and prior to the distribution being processed.
Please allow thirty (30) to forty-five (45) days ofter this completed authorization is received by the Fund for payments tobe deposited.
Name:
Frat dale Tat
Home Phone: SSN:
Cell Phone: Alt or Member ID:
Attach ONE of the following:
‘© Voided Check: The voided check is required to have the financial institution's name and payee's name pre-
printed on the check along with the routing and account number.
Bank Letter or Statement: The bank letter or statement is required to be on bank letterhead and have the
Payee's name, account type, complete routing and account number pre-printed on document.
I hereby request the International Painters and Allied Trades Industry Pension Fund to deposit my benefit
payments into the account stated in the attached document.
Participant/Annuitant Signature: Date: fy
‘Must be signed in the presence ofa Notary Public.
tate of County of
, 2 Notary Public, on this day personally
ppeared, known to me to be the person whose name is
rte Name of Person Appeared Before Notary
tubscribed to the foregoing instrument and acknowledged to me that he/she executed the same for purposes
ind consideration therein expressed. Given under my hand and seal of office this day of
Day ‘onth
0
Notary Signature:
ate Notary Commission Expires: {seal or tome)
Revised JUNE2028
