State Form 946r2 - Change Of Name And/or Address - Public Employee'S Retirement Fund - Indiana

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Public Employees' Retirement Fund
Change of Name and/or Address
Please Check One:
Date: _______________________
Retired Member
Refundee
Active Member
Social Security Number: _____________________________________________________________
According to IRS Regulations, Section 6041(A), we are required to obtain your Social Security Number. This
form cannot be processed without it.
Name and/or Address Now Shown on PERF Records
First
Middle
Maiden
Last
Street
City
State
ZIP Code
Change Name and/or Address To:
First
Middle
Maiden
Last
Street
City
State
ZIP Code
For Active Members: Employer, Department, Institution, and Unit:
__________________________________________________________________________________
_________________________________________
____________________________________
Signature
Date
Return Form to:
Public Employees' Retirement Fund
143 West Market Street Suite 800
State Form 946R2
Indianapolis, IN 46204
Approved by the State Board of Accounts 1996

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