Fillable Name And Address Change Form - Omrf printable pdf download

Clear Form

Oklahoma Municipal Retirement Fund

NAME AND ADDRESS CHANGE FORM

PERSONAL INFORMATION

(please print clearly using blue or black ink)

NAME: ____________________________________________________________ SOCIAL SECURITY NUMBER: ______________________

FORMER ADDRESS: ____________________________________________________________________ APT: ______________________

CITY: ________________________________________________________________ STATE: _____ ZIP CODE: ______________________

DAY PHONE: ___________________________________________________ EVENING PHONE: ___________________________________

EMAIL: ________________________________________________________________________ DATE OF BIRTH: _____ /_____ /______

EMPLOYER NAME: ____________________________________________ STATUS

ACTIVE

SEPARATED FROM SERVICE

(please select one)

NEW ADDRESS/PHONE NUMBER INFORMATION

(please print clearly using blue or black ink)

NEW ADDRESS: _______________________________________________________________________ APT: ________________________

CITY: ________________________________________________________________ STATE: ________ ZIP CODE: ________________ ______

NEW DAY PHONE: _________________________________________ NEW EVENING PHONE: ________________________________________

NAME CHANGE INFORMATION

(please print clearly using blue or black ink)

NEW NAME: _____________________________________________________________________________________________________

PREVIOUS NAME: _________________________________________________________________________________________________

AUTHORIZATION

(signatures required)

As the participant I certify, under penalty of perjury, that to the best of my knowledge and belief the information provided on this form, including the

Taxpayer Identification Number (social security number), is accurate and complete.

PARTICIPANT SIGNATURE: ___________________________________________________________________ DATE: ____________________

PARTICIPANT SIGNATURE MUST BE WITNESSED BY A NOTARY PUBLIC

State of: ___________________________________________

County of: _______________________________________________

On this ____ day of ____________________, 20_____, before me personally appeared ____________________________________________,

to be known to be the participant described above and who executed the same.

Witness my hand and official seal.

________________________________________________________________My Commission expires: ______________________________

Notary Public

PLEASE NOTE: Supporting documentation must accompany this request. For address changes, please provide a current utility bill with new address.

For name changes, a copy of your marriage certificate, divorce decree, driver’s license or other legal documentation.

Please submit your completed form with supporting documentation to:

VIA FAX

VIA MAIL

VIA OVERNIGHT DELIVERY

Voya Financial

Attn: Oklahoma Municipal Retirement Fund

1-844-206-7965

P.O. Box 24747

8900 Freedom Commerce Parkway

Jacksonville, FL 32241-4747

Jacksonville, FL 32256-8264

If you have any questions, you may call the Service Center at 1-844-466-5673, or to obtain additional plan or account information, please access your account

at Customer Service Representatives are available Monday through Friday, 7:00 A.M. to 7:00 P.M. Central Time (excluding stock

market holidays).

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OK454OK1ADDCHAN

07/15/2015