Form Vrs-900 - Authorization To Discuss Vrs Account Information
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1AUTHORIZATION TO DISCUSS VRS ACCOUNT INFORMATION
1.
Social Security Number
VIRGINIA RETIREMENT SYSTEM
P.O. Box 2500 Richmond, Virginia 23218-2500
Toll Free 1-888-VARETIR (827-3847)
2.
Home Phone Number
Clear Form
Complete this form to allow Virginia Retirement System (VRS) representatives to speak to the individual(s) you list below
regarding your benefits under VRS and your account information. The listed individual(s) may only discuss your benefits
and account information; they may not take actions that affect your account.
Note: Completing this form does not allow VRS representatives to discuss the following types of information with anyone
other than the member: bank account and bank routing numbers, medical records, beneficiary information, or details of
Approved Domestic Relations Orders. To allow individuals to take actions on your behalf, you may prefer to complete a
VRS Durable Power of Attorney (VRS-901), which is available on the VRS Web site at .
Important Information:
•
This authorization expires two years from the date of the notary signature.
•
You do not need to complete this form if a Durable Power of Attorney is on file at VRS.
PART A. MEMBER INFORMATION
3.
Name
(First, Middle Initial, Last)
4.
Address
(Street, City, State and Zip+4)
Retiree
Member
Other, please explain:
5.
Member Status
PART B. AUTHORIZATION OF INDIVIDUALS
List the individual(s) to whom VRS representatives may speak regarding your VRS retirement benefits and account
information.
Individual’s Full Name
Relationship to You
Last 4 Digits of SSN
Birth Date
I hereby authorize VRS representatives to discuss information about my VRS retirement benefits and member account information
with the individuals named above. I understand this authorization expires two years from the date of my signature below.
(Place photographically reproducible seal below)
____________________________________________________
Signature
TO BE COMPLETED BY NOTARY
or by other Court Official authorized to take acknowledgments:
STATE OF
City/ County of
On this _______ day of _______________________________ , ______________,
the member whose name is signed above, personally appeared before me and
acknowledged the foregoing signature to be his/hers, and having been duly sworn
by me, made oath that the statements made in the said instrument are true.
Commission Expiration Date
Notary Signature
Registration No. (VA Notary Only)
VRS-900 (Rev. 02/11)
*VRS-000900*
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