Check Reissue Request Form (code BK6)

CHECK REISSUE REQUEST FORM
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
XX X X X
Apt. No. TRS Membership/Retirement/Beneficiary Number
City State Zip Code
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Member’s Change of Address Form” (code DM13) or, if applicable, a “Beneficiary’s Change of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date:
• Please complete this form if you are requesting that TRS mail you a new check to replace an outdated, torn, defaced, or
incomplete check.
• Please note that you must attach to this form the check that you would like reissued. The returned check should be
marked “VOID.”
• Processing your completed form should take approximately 15 business days from the date on which TRS receives it.
• TRS will mail your new check to the address indicated in Part A of this form.
• If you have any questions, please contact TRS’ Member Services Center at 1 (888) 8-NYC-TRS.
PART B: Please check the appropriate box below.
I am an in-service member of TRS.
I am a retired member of TRS.
I have resigned or been terminated from my TRS-eligible position.
I am the beneficiary of a deceased TRS member.
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PART C: Only if you are filing this form as a beneficiary, please complete the following information about the deceased TRS member.
If you are a TRS member, complete Part A instead.
First Name
MI Last Name Social Security Number
TRS Membership/Retirement Number
PART D: Please check the appropriate box below and provide the requested information about the check in question.
I am filing this form to request a new check to replace an outdated, torn, defaced, or incomplete check.
Type of check: _________________________
Check number: _________________________
Date of check: _________________________
Amount of check: $ ______________________
PART E: Please complete the following and sign below. If you are unable to sign this form, please contact TRS’ Member Services
Center at 1 (888) 8-NYC-TRS.
I, ________________________________________, being duly sworn, depose and say that I am returning (an) outdated, torn, defaced,
or incomplete ____________________ check(s) to TRS for reissue. I understand that TRS will mail the new check(s) to the address
indicated in Part A of this form.
SIGNATURE____________________________________________________
DATE (M/D/Y)_____________________________
PART F: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.)
State of _____________________________ )
) s.s.:
County of _ __________________________ )
On the _______________ day of __________________________, ___________, before me personally appeared the person
known to me to be_______________________________________________________________________________, the individual
who executed the foregoing instrument and acknowledged to me that (s)he executed the same.
Signature:_ _____________________________________________________
Official Title:_____________________________________________________
Expiration Date of Commission:_ ____________________________________
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