Free 00946.pdf - Indiana

REQUEST FOR CHANGE OF NAME AND/OR ADDRESS
State Form 946 (R4 / 8-08)

Reset Form

* PRIVACY NOTICE All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory; this form will not be processed without the information

INSTRUCTIONS: 1. Please TYPE or PRINT. Use black ink. 2. Complete all information. Remember to include the Social Security Number. 3. Return the completed form directly to PERF. Do not return the instruction page.

STEP 1: Select one. Active Member Benefit Recipient

STEP 2: Information PERF presently has for me.
Social Security Number *


First name Mailing address (number and street) Middle name / initial Last name


City Home telephone number State Other telephone number ZIP code

( )
E-mail address

(

)

STEP 3: Information I wish to change / update.
First name Mailing address (number and street) Middle name / initial Last name


City Home telephone number State Other telephone number ZIP code

( )
E-mail address

(

)



I certify that, to the best of my knowledge, the information provided in this form is true and accurate.
Signature Date (month, day, year)

INSTRUCTIONS FOR COMPLETING STATE FORM 946, REQUEST FOR CHANGE OF NAME AND/OR ADDRESS IMPORTANT: 1. Remove the form. Do not return these instructions to PERF. 2. Please type or print. Use black ink. 3. Complete all information. Remember to include your Social Security Number. 4. Return the completed form directly to PERF at the address below. STEP 1: Select one. If you are changing your own information, check the Active Member box. If you are the surviving beneficiary of a member, check the Benefit Recipient box. STEP 2: Information PERF presently has for me. Member / Recipient Social Security Number: Enter all nine digits of the Social Security Number. Your application will not be processed without this information. Member / Recipient First Name: Enter the first name. Member / Recipient Middle Name or Initial: Enter the middle name or initial. Member / Recipient Last Name: Enter the last name. Member / Recipient Address: Enter the current full street address. City: Enter the city. State: Enter the state. ZIP Code: Enter the five or nine-digit ZIP code. Member / Recipient Telephone Number: Enter the current telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail address: Enter the E-mail address, if available. STEP 3: Information I wish to change / update. Important! Enter only the information that you wish PERF to update. If you are requesting a change of name, you must include the appropriate legal documentation: a copy of your Marriage License, Divorce Decree, or Court Order. You must attach an English translation to any foreign language document. Member / Recipient First Name: Enter the first name. Member / Recipient Middle Name or Initial: Enter the middle name or initial. Member / Recipient Last Name: Enter the last name. Member / Recipient Address: Enter the current full street address. City: Enter the city. State: Enter the state. ZIP Code: Enter the five or nine-digit ZIP code. Member / Recipient Telephone Number: Enter telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail address: Enter the E-mail address, if available. WHEN THE FORM IS COMPLETE, YOU MUST SIGN AND DATE IT, THEN RETURN THE FORM TO PERF. Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the Public Employees' Retirement Fund at the following address: Public Employees' Retirement Fund 143 West Market Street Indianapolis, IN 46204 HELPFUL INFORMATION PERF TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-(888) 526-1687 TDD (hearing impaired number) (317) 233-4160 PERF FAX Number (317) 234-5922 PERF on the Internet: www.in.gov/perf E-MAIL: [email protected] PERF MEMBER HANDBOOK (latest edition) PERF ANNUITY SAVINGS ACCOUNT INVESTMENT HANDBOOK