Transcription of Electronic Funds Transfer enrollment form
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Electronic Funds Transfer enrollment form
Please print using blue or black inkFor use by structured settlement annuitants/payees onlyInstructions To enroll in Prudential s Electronic Funds Transfer (EF T) payment service, please provide us with the following information and enclose your blank, voided check for the account into which Prudential will deposit your payments. However, if a savings account is being used, you must fi rst check with your bank to obtain the correct bank transit routing number and account number for Electronic deposits. Note: We cannot obtain acceptable banking information from deposit slips. Call us toll-free at 1-877-778-8118 with any information _____Contract number_____ _____ _____First name of annuitant Middle initial Last name of annuitant_____ _____ _____First name of joint annuitant (if any) Middle initial Last name of joint annuitant_____ _____Annuitant address Apt_____ _____ _____City State ZIP
To enroll in Prudential’s electronic funds transfer (EFT) payment service, please provide us with the following information and enclose your blank, voided check for the account into which Prudential will deposit your payments.
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