Change Of Address
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1Louisiana Sheriffs’ Pension & Relief Fund
1225 Nicholson Dr. – Baton Rouge, LA 70802
225-219-0500 – Fax: 225-219-0521
Change of Address
PRINT OR TYPE ALL INFORMATION AND UPON COMPLETION, SUBMIT VIA MAIL OR FAX
SECTION 1: MEMBER / RECIPIENT INFORMATION
Check One:
Active
Inactive
Retired
Recipient
Member’s First Name
Middle
Last
Social Security Number
Date of Birth (MM/DD/YYYY)
Daytime Area Code and Telephone Number
Evening Area Code and Telephone Number
Recipient Information – if different than Member
Recipient’s First Name
Middle
Last
Social Security Number
Date of Birth (MM/DD/YYYY)
SECTION 2: CHANGE OF ADDRESS / CERTIFICATION
Former Mailing Address
New Address
City
State
Zip
City
State
Zip
I hereby certify that the information provided on this form is accurate and request changes to my record as indicated above.
Member’s / Recipient’s Signature
Date (MM/DD/YYYY)
SECTION 3: AUTHORIZATION, IF NECESSARY
If signing with an “X” or your signature has changed due to health reasons, please sign this form in the presence of
a Notary Public. If you have granted Power of Attorney to an individual and our office has a copy of the official
document on file, he / she may complete this form.
A Power of Attorney form specifically pertaining to the
Louisiana Sheriffs’ Pension Fund is available upon request.
SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of _____________________________
parish/county of ____________________________ this __________________ day of _______________, 20___________
_____________________________________________________ ______________________
NOTARY PUBLIC (Signature)
Notary ID # or Bar Roll #
(affix seal here)
____________________________________________________________________________
NOTARY PUBLIC (Type, print or stamp name)
Commission Expires: __________________
RETAIN A COPY FOR YOUR RECORDS
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