Change Of Personal Information Form - Public Employees' Retirement System Of Nevada
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1Public Employees’ Retirement System of Nevada
693 W. Nye Lane, Carson City, NV 89703 (775) 687-4200 Fax (775) 687-5131
5740 S. Eastern Ave. Suite 120, Las Vegas, NV 89119 (702) 486-3900 Fax (702) 678-6934
Toll Free 1-866-473-7768 Website:
Email:
CHANGE OF PERSONAL INFORMATION
FORM
This form is for members who have not yet retired and are not collecting monthly benefits from
PERS to change, update or correct account information.
Name: ______________________________________ SSN: _____________________
If name has changed, please list previous name(s)
: ________________________________________
M
F
Gender:
Birth Date: ____________________________________
Single
Married
Widowed
Marital Status:
Current Address:
(Members who have not retired may also change their address online at our website)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Home Phone: _______________________ Work Phone: _________________________
Personal Email:
This form updates personal information only and does not change beneficiaries listed on
your Survivor Beneficiary Designation Form.
Signature: __________________________________________ Date: ______________
For PERS Use – Date Stamp
Revised 2/17
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