Payment Recipient Address Change Request Form printable pdf download

Payment Recipient Address Change Request Form

Public Employees Retirement Association

60 Empire Drive, Suite 200, St Paul, MN 55103-2088

Telephone: (651)296-7460; or Toll Free 1 (800) 652-9026

Fax: (651) 297-2547

Payment Recipient Address Change Request Form

To be completed by payment recipients.

PART A—PAYMENT RECIPIENT INFORMATION:

Name—Last, First, and Middle Initial (Please Print)

Social Security Number (last four digits)

PERA ID Number

XXX-XX

-_________

PART B—PREVIOUS ADDRESS INFORMATION:

Previous Street Address (Please Print)

APT NO. (if applicable)

City, State, and Zip Code

PART C—NEW ADDRESS INFORMATION:

New Street Address (Please Print)

APT NO. (if applicable)

City, State, and Zip Code

Effective Date of New Address

PART D—SIGNATURE REQUIRED

This form must be completed and signed by the payment recipient or a legal representative of the payment recipient

(under a Power of Attorney agreement or court-ordered Conservatorship, for example). Legal representatives should

include a copy of any agreement or court order granting the legal representative the authority to act on behalf of the

payment recipient with this form.

_________________________________________________

__________________

Signature of Payment Recipient or Legal/Representative

Date

Rev. March 2013 jep

Payment Recipient Address Change Request Form