CHANGE OF ADDRESS FORM Return this Form to: MPI P.O. Box 1999 Studio City, CA 91614-0999 Toll Free: (855) 275-4674 Fax: (818) 766-1229 Email: [email protected] PARTICIPANT ADDRESS CHANGE INFORMATION Please Select One Participant Retiree/Survivor Spouse Child Address Type Physical Mailing Third Party* Type: Name MPID / SSN Date of Birth New Address Effective Date(s) City State Zip Email Phone Fax * If you would like personal health information to be sent to someone other than yourself, you need to complete an Authorization for Release of Health Information. If you are requesting the release of your Health and/or Pension information to a person with a Power of Attorney, Conservator or any third party, you must have the required legal documentation on file with MPI. Additional information and required forms for releasing your Health and Pension information may be found at www.mpiphp.org. DEPENDENT/BENEFICIARY ADDRESS CHANGE INFORMATION (This form cannot be used to designate new beneficiaries) Name New Address MPID / SSN Same as Participant’s Above City Zip Email Name Phone MPID / SSN Date of Birth Same as Participant’s Above City Effective Date(s) State Relationship Zip Email Name New Address Effective Date(s) State Relationship New Address Date of Birth Phone MPID / SSN Date of Birth Same as Participant’s Above City Relationship Effective Date(s) State Zip Email Phone PARTICIPANT’S CONSENT I understand that the information I provided above will be used to update my records for both the Motion Picture Industry (MPI) Pension and Health Plans. I must provide separate notification to all Employers, Local Unions and Credit Unions. I further understand that I must submit this form to the address above each time this information changes to ensure I receive Plan information. My signature is required to validate the information on this form. Participant’s Signature Date If you would like to receive MPI Publications via email, please log-in to your MPI account at www.mpiphp.org and complete the “Go Green” process.
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