Beneficiary`s Change of Address Form (code DM14)

BENEFICIARY’S CHANGE OF ADDRESS FORM
INSTRUCTIONS
PLEASE READ CAREFULLY
• The “Beneficiary’s Change of Address Form” is for beneficiaries who are receiving monthly benefit
payments from TRS, or who have established a Tax-Deferred Annuity (TDA) Program account with TRS
under Chapter 677 of the Laws of 2003. (In-service TRS members and retirees should instead submit a
change of address online by accessing our website or by filing a paper “Member’s Change of Address
Form” (code DM13) with TRS; you may obtain this form by accessing the secure section of our website.)
• Upon receipt of this form, TRS will update its records with your new permanent home address and/or
other contact information. TRS will direct all future communications to the home address and/or other
contact information that you indicate in Part B of this form. TRS will send you a written confirmation
of all changes.
• Please note that you may also provide TRS with notification of a change to your permanent home
address and/or other contact information on any TRS form that must be notarized.
In Part A: All information, including your current (or previous) address, must be provided.
In Part B: You must enter your new current home address and/or other contact information. Please do not indicate a
temporary or secondary home address. Instead, TRS suggests that you consult the U.S. Postal Service about having your
mail forwarded on a temporary basis.
In Part C: You must provide all information about the deceased TRS member.
In Part D: If you are receiving benefit payments from TRS, you must indicate whether they are sent to a bank via Electronic
Fund Transfer (EFT) or Direct Deposit. If you want to initiate EFT of your benefit payments, you may apply to do so by filing
an “EFT Authorization Form” (code BK58). This form is available by accessing our website.
In Part E: You must sign and date this form.
In Part F: You must have this form notarized.
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PAGE 1
BENEFICIARY’S CHANGE OF ADDRESS FORM
Please read the instructions before completing this 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. If information is preprinted below, it represents the address and/or phone number
that TRS currently has on file for you. If information is not preprinted below, please provide your previous address and primary
phone number.
Beneficiary’s First Name
MI Last Name
Gender
M
Previous Permanent Home Address
City
Apt. No.
State
Zip Code
Social Security Number
F
TRS Beneficiary/TDAB Membership Number
Daytime Phone Number
()
(Check one:
Home
Work)
Email Address
PART B: Please enter your new current home address and/or other contact information below.
New Permanent Home Address
City
State
Apt. No.
Daytime Phone Number
()
(Check one:
Home
Work)
Zip Code
Email Address
PART C: Please complete the following information about the deceased TRS member.
First Name
MI Last Name Social Security Number
TRS Membership/Retirement Number
PART D: If you are receiving benefit payments from TRS, please provide the following information.
Are your benefit payments currently sent to a bank via EFT or Direct Deposit?
Yes
No
PART E: Please sign and date below.
I certify that the home address and/or other contact information indicated in Part B of this form is/will be my new permanent home
address and/or other contact information. I understand that TRS will direct future communications to this home address and/or
other contact information. I understand that the updated information I have provided on this form will remain on TRS’ records until
superseded by my filing of a subsequent change of address and/or other contact information with TRS.
BENEFICIARY’S SIGNATURE_____________________________________________________ DATE (M/D/Y)_________________
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PAGE 2
CONTINUED FROM PAGE 2
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.:
Country 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: _______________________________________
DM14 (11/15) PAGE 3