Form 2190 "Address Change Authorization" - California

What Is Form 2190?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 2190 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form 2190 "Address Change Authorization" - California

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P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Address Change Authorization
Participant Information
Section 1
Please include your
first name, middle
initial and last
Participant's Full Name
name.
Social Security Number or CalPERS ID
Change Requested
Update my address for mailing my checks or direct deposit slip
Change my physical address
Change my address for mailing other information
New Address Information
Section 2
Please fill in your
correct mailing
address.
In Care of (if applicable)
If you have health
coverage through
Address
CalPERS your mailing
address cannot be a
P.O.Box
P.O. Box
City
State
Zip Code
*If you are changing to
a foreign address
please provide
Province/Territory and
Province/Territory*
Country*
Country
Please include country
code if using a foreign
Telephone Number
telephone number
Required Signature
Section 3
Acknowledgement:
Signature and Date
are required
I am a Guardian/Conservator or have Power of Attorney for the person entitled to the allowance. (A
copy of Guardian/Conservators/Power of Attorney papers must be on file with CalPERS before an
address change will be completed.)
Signature
Date (mm/dd/yyyy)
my|CalPERS 2190
Page 1 of 1
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Address Change Authorization
Participant Information
Section 1
Please include your
first name, middle
initial and last
Participant's Full Name
name.
Social Security Number or CalPERS ID
Change Requested
Update my address for mailing my checks or direct deposit slip
Change my physical address
Change my address for mailing other information
New Address Information
Section 2
Please fill in your
correct mailing
address.
In Care of (if applicable)
If you have health
coverage through
Address
CalPERS your mailing
address cannot be a
P.O.Box
P.O. Box
City
State
Zip Code
*If you are changing to
a foreign address
please provide
Province/Territory and
Province/Territory*
Country*
Country
Please include country
code if using a foreign
Telephone Number
telephone number
Required Signature
Section 3
Acknowledgement:
Signature and Date
are required
I am a Guardian/Conservator or have Power of Attorney for the person entitled to the allowance. (A
copy of Guardian/Conservators/Power of Attorney papers must be on file with CalPERS before an
address change will be completed.)
Signature
Date (mm/dd/yyyy)
my|CalPERS 2190
Page 1 of 1
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1. Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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