Free change.PDF - Washington


File Size: 126.6 kB
Pages: 1
Date: May 31, 2007
File Format: PDF
State: Washington
Category: Workers Compensation
Author: rilj235
Word Count: 139 Words, 819 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/242107af.pdf

Download change.PDF ( 126.6 kB)


Preview change.PDF
Labor and Industries Pension Benefits Section PO Box 44281 Olympia WA 98504-4281

ADDRESS CHANGE REQUEST

(360) 902-5119 Effective Date NAME Please check one: Pensioner Widow/er Dependent Power of Attorney/Guardian Claim # Folio #

New Mailing Address

City

State

ZIP+4

Please provide us with the telephone number you would prefer to be contacted at: Work Telephone Number (if applicable) Home Telephone Number

Signature

Date

(PLEASE NOTE that any change of address must be received in this office no later than the 8th of the month to effect payments scheduled to be mailed to you on the 15th of the month. (This does not effect those who have direct deposit.) Should you choose, for quick arrival, you may fax your request back to the department at (360) 902-6455.

F242-107-000 address change request 06-2007