Change of Address Form RECEIVED For Active Members Only (not retirees) Office of the New York State Comptroller New York State and Local Retirement System Employees’ Retirement System Police and Fire Retirement System 110 State Street, Albany, New York 12244-0001 RS 5512 (Rev. 11/12) PLEASE PRINT CLEARLY USING CAPITAL LETTERS. USE ONLY BLUE OR BLACK INK. STAY WITHIN BOXES. LEAVE BLANK BOXES BETWEEN WORDS AND NUMBERS. Registration Number (if known) Last 4 Digits of Social Security Number* Maiden or Other Name Used Date of Birth – Month Last Name Day First Name Year M.I. Old Address Information: Street Address City State Zip Code New Address Information: Street Address 1 Street Address 2 City State Zip Code – Daytime Telephone Number ( ) E-mail Address Signature Date Month Day Year This form cannot be processed without your signature. Mail this completed form to: New York State and Local Retirement System Member & Employer Services Registration – Mail Drop 5-6 110 State Street Albany NY 12244 PERSONAL PRIVACY PROTECTION LAW In accordance with the Personal Privacy Law you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain records. The records are necessary to determine eligibility for and to calculate benefits. Failure to provide information may result in the failure to pay benefits. The System may provide certain information to participating employers. The official responsible for maintaining these records is the Director of Member and Employer Services, New York State and Local Retirement Systems, Albany, NY 12244; telephone number (518) 474-3524. *SOCIAL SECURITY DISCLOSURE REQUIREMENT In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to Sections 11, 31, 34 and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.
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