"Payment Recipient Address Change Request Form" - Minnesota

Payment Recipient Address Change Request Form is a legal document that was released by the Minnesota Public Employees Retirement Association - a government authority operating within Minnesota.

Form Details:

  • Released on March 1, 2013;
  • The latest edition currently provided by the Minnesota Public Employees Retirement Association;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Public Employees Retirement Association.

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Download "Payment Recipient Address Change Request Form" - Minnesota

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Public Employees Retirement Association
60 Empire Drive, Suite 200, St Paul, MN 55103-2088
Telephone: (651)296-7460; or Toll Free 1 (800) 652-9026
Fax: (651) 297-2547
Payment Recipient Address Change Request Form
To be completed by payment recipients.
PART A—PAYMENT RECIPIENT INFORMATION: 
Name—Last, First, and Middle Initial (Please Print)
Social Security Number (last four digits)
PERA ID Number
XXX-XX
-_________
 
 
PART B—PREVIOUS ADDRESS INFORMATION: 
Previous Street Address (Please Print)
APT NO. (if applicable)
City, State, and Zip Code
 
PART C—NEW ADDRESS INFORMATION: 
New Street Address (Please Print)
APT NO. (if applicable)
City, State, and Zip Code
Effective Date of New Address
 
 
PART D—SIGNATURE REQUIRED 
This form must be completed and signed by the payment recipient or a legal representative of the payment recipient
(under a Power of Attorney agreement or court-ordered Conservatorship, for example). Legal representatives should
include a copy of any agreement or court order granting the legal representative the authority to act on behalf of the
payment recipient with this form.
_________________________________________________
__________________
Signature of Payment Recipient or Legal/Representative
Date
 
 
Rev. March 2013 jep
Public Employees Retirement Association
60 Empire Drive, Suite 200, St Paul, MN 55103-2088
Telephone: (651)296-7460; or Toll Free 1 (800) 652-9026
Fax: (651) 297-2547
Payment Recipient Address Change Request Form
To be completed by payment recipients.
PART A—PAYMENT RECIPIENT INFORMATION: 
Name—Last, First, and Middle Initial (Please Print)
Social Security Number (last four digits)
PERA ID Number
XXX-XX
-_________
 
 
PART B—PREVIOUS ADDRESS INFORMATION: 
Previous Street Address (Please Print)
APT NO. (if applicable)
City, State, and Zip Code
 
PART C—NEW ADDRESS INFORMATION: 
New Street Address (Please Print)
APT NO. (if applicable)
City, State, and Zip Code
Effective Date of New Address
 
 
PART D—SIGNATURE REQUIRED 
This form must be completed and signed by the payment recipient or a legal representative of the payment recipient
(under a Power of Attorney agreement or court-ordered Conservatorship, for example). Legal representatives should
include a copy of any agreement or court order granting the legal representative the authority to act on behalf of the
payment recipient with this form.
_________________________________________________
__________________
Signature of Payment Recipient or Legal/Representative
Date
 
 
Rev. March 2013 jep