GERS_Request_for_Change_of_Name
REQUEST FOR CHANGE OF NAME 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: ________________________________________________________________ MAILING ADDRESS:___________________________________________________________________ ___________________________________________________________________ SOCIAL SECURITY NUMBER: ___________________________________________________________ OLD NAME: _________________________________________________________________________ NEW NAME:_________________________________________________________________________ REASON FOR NAME CHANGE: J Change in Marital Status J Court Order J Religion (Please provide marriage (Please provide certificate or divorce decree) court order) J Other (Please specify) _____________________________________________________________ ______________________________________________________________ …
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REQUEST FOR CHANGE OF NAME 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: ________________________________________________________________ MAILING ADDRESS:___________________________________________________________________ ___________________________________________________________________ SOCIAL SECURITY NUMBER: ___________________________________________________________ OLD NAME: _________________________________________________________________________ NEW NAME:_________________________________________________________________________ REASON FOR NAME CHANGE: J Change in Marital Status J Court Order J Religion (Please provide marriage (Please provide certificate or divorce decree) court order) J Other (Please specify) _____________________________________________________________ ____________________________________________________________________________________ _______________________________________________ Signature of Retiree / Active Employee vvvvvvvv GERS-BEN112 REV 06 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