Form 1c - 2012 Change Of Information Form

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Change of Information
Form 1C – Revised 8/1/2012
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Fill in your name as currently filed with PERS and use sections 2 and 3 to submit new information before
Member/Benefit Recipient Information
certifying information in Section 4.
First Name: ____________________________ MI: _______ Last Name: ______________________________________  Member  Benefit Recipient
Social Security No.: _______________________________________ Birth Date mm/dd/ccyy: _________________________________ Gender:  M  F
Check items to be updated then fill in only applicable information.
Change of Member/Benefit Recipient Information
Effective Date mm/dd/ccyy: __________________
To Change
New Information
____ Name
First Name: ____________________________ MI: _______ Last Name: _____________________________________________
____ Address
Mailing Address: _________________________________ City: _________________________ State: _______ Zip: ___________
____ E-Mail
________________________________________________________________________________  Cellular  Home  Work
____ Phone
________________________________________________________________________________  Cellular  Home  Work
____ Phone
________________________________________________________________________________  Cellular  Home  Work
____ Phone
Use additional Form 1C, Change of Information, if listing more than four dependent children. Information is for
Change of Family Information
determining statutory benefits only. Use Form 1B, Beneficiary Designation, to officially designate any and all beneficiaries. If changes to marital status are
attach a copy of the marriage, divorce, or death certificate.
Select one. Add date for last three.
Effective Date mm/dd/ccyy: ________________
 Single
 Married
 Divorced
 Widowed
Marital Status
Birth Date mm/dd/ccyy
Wedding Date mm/dd/ccyy
Spouse’s Full Name
Social Security No.
_______________________  M  F
_____________________________________ ____________________________ _______________________
Dependent Child’s Full Name – Up to age
Birth Date mm/dd/ccyy
Social Security No.
19, or 23 if unmarried and a full-time student
_______________________  M  F
_____________________________________ ____________________________ _______________________
_______________________  M  F
_____________________________________ ____________________________ _______________________
_______________________  M  F
_____________________________________ ____________________________ _______________________
_______________________  M  F
_____________________________________ ____________________________ _______________________
Active members should sign and submit form to employer for completion of Section 5. Employers will be
Member/Benefit Recipient Certification
responsible for submitting completed form to PERS, if necessary. Inactive members and benefit recipients should sign and submit form directly to PERS,
as Section 5 is not applicable to these individuals.
If an authorized representative signs this form, attach a copy of the durable power of attorney,
conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
Member/Benefit Recipient‘s Signature: ________________________________________________________ Date mm/dd/ccyy:______________________
This section must be completed by an authorized employer representative, not the member. Employer certification of name
Employer Certification
change is required for active members to ensure consistency in the name used for reporting PERS, Social Security, and W-2 wage information. All
employee name and address changes must be entered into WEB-ERS. Completion of Section 5 and submission to PERS by employers is only
necessary when changes are being made to employee phone number(s), e-mail, marital status, or family information.
Employer Name: ____________________________________________________________ Employer No.: _________________ - __________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
As employer representative, I certify that the name change information provided above is consistent with the active member’s name used on the employer’s
records for reporting PERS, Social Security, and W-2 wage information.
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005
601.359.5262, fax
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