GERS_Request_for_Change_of_Address
REQUEST FOR CHANGE OF ADDRESS PLEASE PRINT J ACTIVE DATE_________—__________—_________________ (mm) (dd) (yyyy) J RETIRED NAME: _____________________________________________________________________________ (First Name) (Middle Initial) (Last Name) DATE OF BIRTH: _________—__________—_________________ (mm) (dd) (yyyy) TELEPHONE NUMBER: ________________________________________________________________ SOCIAL SECURITY NUMBER: ___________________________________________________________ OLD ADDRESS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ NEW ADDRESS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ EFFECTIVE DATE OF ADDRESS CHANGE: _________—__________—_________________ (mm) (dd) (yyyy) _______________________________________________ Signature of Retiree / Active …
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REQUEST FOR CHANGE OF ADDRESS PLEASE PRINT J ACTIVE DATE_________—__________—_________________ (mm) (dd) (yyyy) J RETIRED NAME: _____________________________________________________________________________ (First Name) (Middle Initial) (Last Name) DATE OF BIRTH: _________—__________—_________________ (mm) (dd) (yyyy) TELEPHONE NUMBER: ________________________________________________________________ SOCIAL SECURITY NUMBER: ___________________________________________________________ OLD ADDRESS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ NEW ADDRESS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ EFFECTIVE DATE OF ADDRESS CHANGE: _________—__________—_________________ (mm) (dd) (yyyy) _______________________________________________ Signature of Retiree / Active Employee _______________________________________________ Signature of Power of Attorney (If you are completing this form as a Power of Attorney or Guardian for a retiree or beneficiary, please attach a copy of your Power of Attorney or Guardianship Award.) v vvvvvvvvv GERS-BEN113 REV 06 Please allow 5-10 business days for this change to take effect. GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497