Retiree`s Change of Name Form (code RP1)

RETIREE’S CHANGE OF NAME FORM
Please read the instructions before completing this application.
(NOTE: Please print in black or blue ink, and initial any changes that you make on this application.)
PART A: Please provide the information below.
First Name
MI Last Name Permanent Home Address
XX X X X
Apt. No. TRS Membership Number
City State Zip Code
Email Address
Social Security Number (last 4 digits only)
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Check here if you entered new contact information above. TRS will then update our records based on what you entered.
Please keep your contact information up to date. You can visit our website to update your contact information anytime, or file a
“Member’s Change of Address Form” (code DM13) with TRS.
PART B: Please complete the following, sign below, and attach a copy of the name-change documentation. As an alternative to filing
this form, you may access the secure section of our website.
I attest that, effective _____________________, my name has legally been changed from ___________________________________________
(Month/Day/Year)
to __________________________________________________ on account of the following reason: ___________________________________
____________________________________________________________________________________________________________________
___________________________________________________________________. I request that TRS’ records be changed accordingly. I further
state that I have made this change for all purposes, and will be known to acquaintances and friends by the changed name. I am attaching a copy of
the pertinent legal document that effects the name change (e.g., divorce decree, marriage certificate, etc.).
MEMBER’S SIGNATURE (Previous Name)__________________________________________ DATE (M/D/Y)_______________
MEMBER’S SIGNATURE (Present Name)___________________________________________ DATE (M/D/Y)_______________
RP1 (10/15) PAGE 1
CONTINUED FROM PAGE 1
PART C: 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: _______________
RP1 (10/15) PAGE 2