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50134 AUTHORIZATION FOR AUTOMATIC PREMIUM DEDUCTION NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM SFN 50134 Rev. 12-2011 NDPERS PO Box 1657 Bismarck North Dakota 58502-1657 701 328- 3900 1-800-803-7377 Fax 701-328-3920 PART A PARTICIPANT IDENTIFICATION Name Last First Middle NDPERS Member ID Last Four Digits of Social Security Number Date of Birth PART B MEMBER AUTHORIZATION I authorize the following insurance premium s to be withheld from the Financial Institution indicated in Part B...
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