Address Change Authorization Form printable pdf download

Address Change Authorization Form

P.O. Box 942715 Sacramento, CA 94229-2715

888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545

California Public Employees' Retirement System

Address Change Authorization

Participant Information

Section 1

Please include your

first name, middle

initial and last

Participant's Full Name

name.

Social Security Number or CalPERS ID

Change Requested

Update my address for mailing my checks or direct deposit slip

Change my physical address

Change my address for mailing other information

New Address Information

Section 2

Please fill in your

correct mailing

address.

In Care of (if applicable)

If you have health

coverage through

Address

CalPERS your mailing

address cannot be a

P.O.Box

P.O. Box

City

State

Zip Code

*If you are changing to

a foreign address

please provide

Province/Territory and

Province/Territory*

Country*

Country

Please include country

code if using a foreign

Telephone Number

telephone number

Required Signature

Section 3

Acknowledgement:

Signature and Date

are required

I am a Guardian/Conservator or have Power of Attorney for the person entitled to the allowance. (A

copy of Guardian/Conservators/Power of Attorney papers must be on file with CalPERS before an

address change will be completed.)

Signature

Date (mm/dd/yyyy)

my|CalPERS 2190

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Address Change Authorization Form

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