Form F291 - Name Change Application
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1NYCERS USE ONLY
F291
*291*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Name Change Application
This application is for members, pensioners, and beneficiaries who have changed their first or last name. In order for NYCERS to
process this application, you must attach proof of a legal name change, such as a copy of a Marriage Certificate, Judgment of
Divorce, or Court Order. Please complete this application and send it to NYCERS at the address above together with the required
proof. Indicate below the document(s) you are attaching as proof of your legal name change. NOTE: If the address you provide on
this form is different from your address in our system, the new address will become your official address in our records.
Should you have any questions, please contact our Call Center at 347-643-3000.
Member Number
OR
Pension Number
Last 4 Digits of SSN
Daytime Phone
(
)
First Name
M.I.
Last Name
in Care of (if applicable)
Address
Apt. Number
City
State
Zip Code
I am a [check only one]:
Member
Pensioner
Beneficiary
I request that my name be changed on NYCERS' records from:
First Name
M.I.
Last Name
To:
First Name
M.I.
Last Name
I am attaching the following document(s) as proof of a legal name change:
Marriage Certificate
Court Order
Judgment of Divorce
Other: _____________________________________________________
Signature
Date
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
Sign this form and have it notarized, THIS PAGE
R12/16
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