"Change of Address Form - Nycers" - New York City

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Download "Change of Address Form - Nycers" - New York City

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F290
NYCERS USE ONLY
*290*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Change of Address Form
This application is for members who wish to change their address that NYCERS has on file. Should you have any questions regarding
this application, please contact our Call Center at 347-643-3000.
Member Number
OR
Last 4 Digits of SSN
Phone Number
Pension Number
(
)
First Name
M.I.
Last Name
New Address:
IN CARE OF (IF APPLICABLE)
Address
Apt. Number
State
Zip Code
City
Previous Address:
IN CARE OF (IF APPLICABLE)
Address
Apt. Number
City
State
Zip Code
If you are currently receiving monthly payments from NYCERS, check one of the following boxes only.
Continue sending my check to the bank.
OR
Cancel sending my check to the bank.
Please send my check to my new address, as listed above.
Signature of Member
Date
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R12/16
Page 1 of 1
F290
NYCERS USE ONLY
*290*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Change of Address Form
This application is for members who wish to change their address that NYCERS has on file. Should you have any questions regarding
this application, please contact our Call Center at 347-643-3000.
Member Number
OR
Last 4 Digits of SSN
Phone Number
Pension Number
(
)
First Name
M.I.
Last Name
New Address:
IN CARE OF (IF APPLICABLE)
Address
Apt. Number
State
Zip Code
City
Previous Address:
IN CARE OF (IF APPLICABLE)
Address
Apt. Number
City
State
Zip Code
If you are currently receiving monthly payments from NYCERS, check one of the following boxes only.
Continue sending my check to the bank.
OR
Cancel sending my check to the bank.
Please send my check to my new address, as listed above.
Signature of Member
Date
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R12/16
Page 1 of 1