Mtrs Change Of Address Form
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1Main Office
Western Regional
Change of Address
One Charles Park
Office
Cambridge, M
02142-1206
One Monarch Place, Suite 510
Form
Phone 617-679-MTRS (6877)
Springfield, M
01144-4028
ax 617-679-1661
Phone 413-784-1711
Retired Member
Online mass.gov/mtrs
ax 413-784-1707
This form is in interactive pdf format,
I N S T R U C T I O N S
M T R S
U S E
O N L Y
which means that you can enter data in
the fields underlined in red, but you
It is vitally important that you keep us informed of any change in your home address, whether
CANNOT SAVE the form with your
temporary or permanent: your retirement allowance checks and direct deposit statements
entered data. Accordingly, if you enter
will not be forwarded. We will also be sending you financial documents and other forms
data onscreen, please print and
(1099–R tax form, verification of eligibility) throughout your retirement.
proofread this form BEFORE you close
the document.
Please send us notification of any change in your address at least 30 days before the
PRINT
effective date of the change; any changes received after the 15th of the month will not be
reflected until the following month. While we cannot accept address changes over the
telephone, we will accept changes via fax. You will, however, still need to send us the original
form.
Please complete this form and return it to our main office.
If you have any questions, please visit us online at mass.gov/mtrs, or feel free to call us at (617) 679-MTRS. Thank you!
P E R S O N A L D ATA
Social Security number
Part
1
Name
Last
First
Middle
I receive my monthly
Mail
Direct deposit
retirement allowance by
(check one):
A D D R E S S U P D AT E
If, from year to year, you regularly reside at a temporary address (for example, you spend winters at your current address and
summers at your temporary address), you still need to notify us every year of the dates you will be at each address.
Permanent Address
Temporary Address, if any
I wish to receive mail at this address
I wish to receive mail at this address from
Part
beginning on ______/______/______
______/______/______ through ______/______/______.
2
and continuing until further notice.
After this time, send mail to my permanent address.
Address _______________________________________________________________
Address__________________________________________________________
___________________________________________________________________
________________________________________________________________
City ______________________________
State ___________
ZIP ____________
City ______________________________
State______
ZIP ____________
Phone (____________) ___________________________________________________
Phone (____________)______________________________________________
M E M B E R ’ S S TAT E M E N T A N D S I G N AT U R E
I, the undersigned, am the benefit recipient named in Part 1. I hereby notify the MTRS that my address is as listed in Part 2, above.
Part
3
Signature ____________________________________________________________________
Date __________________________
Printed on recycled paper
Form F0011-CAR-0111
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