New York City

1 Offi ce Use OnlyNew york CityPolice Pension Fund Serving the Finest START or CHANGE Electronic Fund Transfer (EFT) Retiree or PayeeDO NOT SUBMIT THIS FORM IF YOU ARE AN ACTIVE MEMBERM ember Information:Tax ID #: _____ Pension #: _____ SSN, Last 4 digits: _____ First Name: _____M: ___ Last Name: _____Address: _____City: _____ State: _____ Zip Code: _____Phone #: (_____) _____-_____ DOB: _____/_____/_____ Please check if this is a new addressPlease check one: Member OR Non-MemberAccount Information:Name of fi nancial institution: _____ABA/Routing # (required for any account type): _____Account Type: Checking SavingsAccount #: _____[PLEASE ATTACH AN UNSIGNED CHECK MARKED VOID] Request type: New ChangeORAcknowledgement:I authorize and direct the fi nancial institution designation herein to immediately refund any overpayments to the New york city Police Pension Fund ( PPF ), including all payments made by the PPF on or after the date of my death, and to charge the same to the designated account.

2 PPF s certifi cation of overpayment shall be suffi cient evidence of an overpayment. If the funds remaining in the account are not suffi cient to permit the fi nancial institution to fully refund overpayments by the PPF, I authorize and direct the fi nancial institution to provide the PPF with all information related to the designated account, including withdrawals after the fi rst of the month in which my death occurs, the names and addresses of all joint account holders and any individuals authorized to withdraw funds from the designated account, and any changes of address within one year prior to the date of my forms mailed or faxed to the Fund MUST BE NOTARIZED.

3 Retiree Signature: _____ Date: _____/_____/_____Notarization:State of_____, County of_____State of_____, County of_____On this_____day of_____, 20___ before me personally On this_____day of_____, 20___ before me personally appeared_____ to me known and appeared_____ to me known and known to me to be the same person described herein and who executed known to me to be the same person described herein and who executed the foregoing instrument, and (s)he duly acknowledged to me that (s)he the foregoing instrument, and (s)he duly acknowledged to me that (s)he executed the same. executed the same. Signature of Notary Public: _____Signature of Notary Public: _____Affi x notary seal or staff name and signature:233 Broadway, 19th Floor, New york , NY 10279 (212) 693-5100 1 of 1 Rev.

4 08/2017