Direct Deposit Enrollment & Changes: SECTION 1: Annuitant Information

Retirement & Income Solutions
Direct deposit enrollment & changes

Use this form to request electronic deposit of payments to your
account or to change your existing bank information.
Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company

Things to know before you begin
● If you have a payment due soon, you may still receive your next You must complete this entire
payment as a check or to the account we have on file. form and sign where indicated
● Payments cannot be deposited into an account outside of the U.S. or your request may be
● Payments that fall on a weekend or holiday will be issued on the delayed.
previous business day (except January 1st, when the payment
must be issued on the first business day of the month).
● If you have more than one benefit, you can list multiple
Annuity numbers and we’ll apply the change to all of them.
● If you’re making this request as a legally approved third party
(Power of Attorney, Guardian, etc.) and we don’t already have
your information on file, you’ll need to include documentation to
support your authority to request the change.
● If you have Medicare Set-Aside payments, they must be placed in
an interest-bearing account, separate from your personal savings
or checking account.
SECTION 1: Annuitant information

First name Middle name Last name
Address City State ZIP
Email address Phone number
Social Security number (last 4 digits) Date of birth (mm/dd/yyyy) Annuity number(s)
Joint Annuitant (if applicable)

SECTION 2: Payee information

Name(s) - If there are joint payees, both payees or their authorized representatives must sign at the end of this
form.
If this request is being made by an authorized party on behalf of the payee(s), confirm your relationship:
Guardian Trustee Conservator Power of Attorney Other
Payee contact information
Complete this section if the payee is different from the Annuitant or the payee's information has changed.
Address City State ZIP
Email address Phone number
Check this box if this is a new address for the payee.

BACH RIS-ARS-BACH-STR (03/21) Page 1 of 3
SECTION 3: Payee account information
● The sample check shown may help you locate checking account numbers. Please reference a check, not a
deposit slip.
● If a savings account is used, please check with your bank for the appropriate routing and account numbers.
● If payments are due to an entity or individual for the benefit of the payee, a copy of a voided check or bank
statement must be submitted with this form.
● If payments are for Medicare Set-Aside (MSA), please attach either a voided check with an account name
that indicates it is for MSA payments or a letter/statement from your bank indicating that the account is
interest bearing and separate from your personal account(s).
Bank name Bank phone number
Bank address City State ZIP
Type of account (check one): Checking Savings

Bank account number
Bank routing number (must be 9 digits)
Check this box if you would like all outstanding payments reissued to the bank account above.
SECTION 4: Authorization
● I request that payments be directly deposited as instructed on this form. This authorization will remain in
effect until a request to change it is received.
● I understand that the insurance company will not be liable for any failure to change or terminate this
agreement until a complete request is received and reasonable time has passed to make the change.
● If any payment is credited to my account in error, I authorize and direct my financial institution to debit the
account and to refund any such overpayment.
● If I checked the box above indicating a new address, I authorize the update of the payee address of record.
If there is a Joint annuitant/payee, both parties or their authorized representatives must sign below.
Annuitant/Authorized signer
Signature Date (mm/dd/yyyy) Annuity number(s)
Joint annuitant/payee (required if applicable)

Signature Date (mm/dd/yyyy)

SECTION 5: How to submit this form
Please complete and sign this form and return by:
Mail: Fax: Email:
Retirement & Income Solutions 1-866-855-2773 [email protected]
PO Box 14710
Lexington KY 40512-4710
We're here to help
You can reach us at 1-800-638-2704, Monday through Friday, 8 a.m. to 9 p.m. Eastern Time.

Direct Deposit Enrollment & Changes: SECTION 1: Annuitant Information

Uploaded by

Copyright:

Available Formats

Direct Deposit Enrollment & Changes: SECTION 1: Annuitant Information

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Direct Deposit Enrollment & Changes: SECTION 1: Annuitant Information

Uploaded by

Copyright:

Available Formats

Retirement & Income Solutions

Direct deposit enrollment & changes

Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company

SECTION 1: Annuitant information

Address City State ZIP

Email address Phone number

Joint Annuitant (if applicable)

SECTION 2: Payee information

Email address Phone number

Check this box if this is a new address for the payee.

Bank address City State ZIP

Type of account (check one): Checking Savings

Bank routing number (must be 9 digits)

Signature Date (mm/dd/yyyy) Annuity number(s)

Joint annuitant/payee (required if applicable)

Signature Date (mm/dd/yyyy)

BACH RIS-ARS-BACH-STR (03/21) Page 2 of 3

BACH RIS-ARS-BACH-STR (03/21) Page 3 of 3

You might also like