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ROUTING #: 281582693

Authorization to Provide Benefit Verification to Credit Union


I authorize MoDOT & Patrol Employees' Retirement System to provide a verification of my benefits to the following Credit Union:
Division 10 Highway Employee's Credit Union
Intended Use of Information: Verification for Loan
This Authorization to Provide Benefit Verification will be effective for 90 days (one-time authorization).
By submitting the form below, I certify that I have read and agree to the Electronic Signature Terms.

Verify Your Identity


Signature

MPERS will not be held responsible for the release and subsequent use of the requested information. I understand that I have the right to revoke this authorization, provided that I do so in writing, except to the extent that MPERS has already used or disclosed the information in reliance on the authorization.


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