Form DRS MS265 "Affidavit of Attorney in Fact" - Washington

What Is Form DRS MS265?

This is a legal form that was released by the Washington State Department of Retirement Systems - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the Washington State Department of Retirement Systems;
  • 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 DRS MS265 by clicking the link below or browse more documents and templates provided by the Washington State Department of Retirement Systems.

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Download Form DRS MS265 "Affidavit of Attorney in Fact" - Washington

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Clear Form
Affidavit of Attorney in Fact
Send completed form to:
Department of Retirement Systems
This form is for making changes to a member’s
PO Box 48380
Olympia, WA 98504-8380
or principal’s account. A “principal” is the person for
www.drs.wa.gov
800.547.6657
whom you are making changes.
360.664.7000
TTY: 711
Important Information
All fields in this form must be filled in or the form will be returned to you.
If you are a health care provider for the member or principal, you cannot serve as attorney in fact for the
member or principal unless you are his or her spouse, registered domestic partner, adult child or sibling. Before
you complete this form, verify that:
The member or principal is alive
The power-of-attorney document is the most recent version and is still valid
Personal Information
Member Name (Last, First, Middle)
Social Security Number
Principal Name (If Different from Member)
Social Security Number
Retirement System(s) and/or Program
c Public Employees’ Retirement System (PERS)
c School Employees’ Retirement System (SERS)
c Teachers’ Retirement System (TRS)
c Washington State Patrol Retirement System (WSPRS)
c Public Safety Employees’ Retirement System (PSERS)
c Law Enforcement Officers’ and Fire Fighters’ Retirement System (LEOFF)
c Judicial Retirement System (JRS)
c Deferred Compensation Program (DCP)
Attorney-in-Fact Information
Name (Last, First, Middle)
Birthdate (mm/dd/yyyy)
Social Security Number
Mailing Address
City
State
ZIP
Email Address
Phone Number
Relationship to Member or Principal
Does He or She Live with You?
c Yes
c No
Notarized Document That Names You Attorney in Fact (Send Copy of Original with This Form)
Proposed Actions I Intend to Take on Behalf of Member or Principal (For Example, Updating Direct Deposit or Tax Information, Etc.)
Are you the member’s or principal’s original attorney in fact or a
Are you the member’s or principal’s doctor, nurse or other
successor attorney in fact?
health care worker?
c Original Attorney in Fact
c Successor Attorney in Fact
c Yes
c No
Are you or have you ever been married to or in a registered
If yes, are you still legally in that relationship?
domestic partnership with the member or principal?
c Yes
c No
c Doesn’t Apply to Me
c Yes
c No
Please complete the other side of this form as well.
DRS MS 265 11/16
*DRSMS265*
Clear Form
Affidavit of Attorney in Fact
Send completed form to:
Department of Retirement Systems
This form is for making changes to a member’s
PO Box 48380
Olympia, WA 98504-8380
or principal’s account. A “principal” is the person for
www.drs.wa.gov
800.547.6657
whom you are making changes.
360.664.7000
TTY: 711
Important Information
All fields in this form must be filled in or the form will be returned to you.
If you are a health care provider for the member or principal, you cannot serve as attorney in fact for the
member or principal unless you are his or her spouse, registered domestic partner, adult child or sibling. Before
you complete this form, verify that:
The member or principal is alive
The power-of-attorney document is the most recent version and is still valid
Personal Information
Member Name (Last, First, Middle)
Social Security Number
Principal Name (If Different from Member)
Social Security Number
Retirement System(s) and/or Program
c Public Employees’ Retirement System (PERS)
c School Employees’ Retirement System (SERS)
c Teachers’ Retirement System (TRS)
c Washington State Patrol Retirement System (WSPRS)
c Public Safety Employees’ Retirement System (PSERS)
c Law Enforcement Officers’ and Fire Fighters’ Retirement System (LEOFF)
c Judicial Retirement System (JRS)
c Deferred Compensation Program (DCP)
Attorney-in-Fact Information
Name (Last, First, Middle)
Birthdate (mm/dd/yyyy)
Social Security Number
Mailing Address
City
State
ZIP
Email Address
Phone Number
Relationship to Member or Principal
Does He or She Live with You?
c Yes
c No
Notarized Document That Names You Attorney in Fact (Send Copy of Original with This Form)
Proposed Actions I Intend to Take on Behalf of Member or Principal (For Example, Updating Direct Deposit or Tax Information, Etc.)
Are you the member’s or principal’s original attorney in fact or a
Are you the member’s or principal’s doctor, nurse or other
successor attorney in fact?
health care worker?
c Original Attorney in Fact
c Successor Attorney in Fact
c Yes
c No
Are you or have you ever been married to or in a registered
If yes, are you still legally in that relationship?
domestic partnership with the member or principal?
c Yes
c No
c Doesn’t Apply to Me
c Yes
c No
Please complete the other side of this form as well.
DRS MS 265 11/16
*DRSMS265*
Attorney-in-Fact Signature (notarization required)
I freely and voluntarily sign this affidavit to establish my authority to act as attorney in fact for the member or principal. I declare
under penalty of perjury under the laws of Washington state that the statements in this affidavit, including my full name and Social
Security Number, are correct.
Attorney-in-Fact Signature
Date
State of
County of
Seal
Date Signed or Attested Before Me
Date My Appointment Expires
or
Stamp
Notary Signature
Notary Name
Notary Title
Notarization is required to process this form.
Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your
Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.
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