name CHanGe FORm

name CHANGE FORM
•Use this form to make a name and/or marital status change in your existing ICMA-RC 457 Deferred Compensation Plan, 401 Money
Purchase Plan, or 401 Profit-Sharing Plan account.
•If you have more than one ICMA-RC account, your name and/or marital status changes will be made to all accounts.
•To change your beneficiary designation or address, please use Account Access (www.icmarc.org).
•Please print legibly in blue or black ink. If you fax the form to ICMA-RC, please do not mail the original.
1. personal information
Employer Plan Number Employer Plan Name
___ ___ ___ ___ ___ ___
State
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___
Social Security Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Full Name of Participant (Please indicate your former name here.)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Last
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
First M.I.
2. Name Change
IMPORTANT: You must attach a copy of a legal document (e.g., driver’s license, marriage certificate, divorce decree) or your name
change will not be processed.
Full New Name of Participant
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Last
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
First M.I.
3. Marital Status Change
New Marital Status - Check one box ❐ Married ❐ Single 4. Authorization
Your signature is required. Please sign this form using your new name.
___________________________________________________ _____ _____ / _____ _____ / _____ _____ _____ _____ Participant Signature Month Day Year
please keep a copy of your completed form for your records
ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 •
En Español 800-669-8216 • www.icmarc.org • Fax 202-682-6439
FRM000-116-1212-6170-1110