Name/address Change
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NAME/ADDRESS CHANGE
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PO Box 48380 Olympia, WA 98504-8380
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Toll Free: 800.547.6657
Olympia Area: 360.664.7000
TTY: 711
Status:
(check all that apply)
c Inactive/Separated
c Retired
c Beneficiary
c Legal Order Payee
Active members: Update your name and/or address through your employer(s).
c Public Employees’
c School Employees’ (non-teachers)
c State Patrol
System:
(check
all that apply)
c Teachers’
c Law Enforcement Officers’ & Fire Fighters’
c Public Safety Employees’
c Judicial
c Deferred Compensation Program
Identification – Please complete in full. Type or print in dark ink.
Full Name (Last, First, Middle)
Gender
Social Security Number
c M
c F
Phone Number
Date of Birth (MM/DD/YYYY)
Email Address
Maiden Name
Name Change – Complete only if your name has changed.
The name you provide to us should be the same as on your Social Security card. A copy of one of the following
documents must accompany this form:
•
Passport
•
NEXUS Card
•
Enhanced ID Card (EID)
•
Driver License
•
Passport Card
•
Certificate of Armed Services Record-DD214
•
Social Security Card
•
Enhanced Driver License (EDL)
Old Name
Full Name (Last, First, Middle)
Effective date of
name change
New Name
Full Name (Last, First, Middle)
MM/DD/YYYY
Address Change – Complete only if your address has changed.
Old Address
Mailing Address
City
State
ZIP
New Address
Mailing Address
Effective date of
address change
City
State
ZIP
MM/DD/YYYY
c Please check this box if you would like your primary beneficiary’s address updated to the New Address listed.
Certification
Note: If this form is completed by anyone other than the person identified in the above Identification section, a copy of either
the power of attorney or court-appointed guardianship papers must be provided before the name or address will be changed.
I certify that my name or address was changed as shown above.
Signature
Date
*DRSMS101*
DRS MS 101 (R 7/14)
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Parent category: Legal