Name Change Form - City of Richmond

Name Change Form
DIRECTIONS
PART A. MEMBER INFORMATION
This form is for retirees or former
employees who would like to change
their name.
Social Security #
Current employees can contact the
Department of Human Resources
and log in to www.icmarc.org to
obtain a Name Change Form from
ICMA-RC, if applicable.
Mailing Address
City/State/ZIP
Phone Number
Email Address
STEP 1
Please fill out your form,
typed or printed in ink,
and remember to sign.
STEP 2
Submit your form...
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3P,
with a photo ID
PART B. OLD AND NEW NAME
OLD First Name
NEW First Name
OLD Last Name
NEW Last Name
OLD Middle Initial
NEW Middle Initial
PART C. ATTACH 1 TO FORM
A marriage certificate
The court document named below:
A divorce order
or
...by mailing your form to:
Richmond Retirement System
730 E. Broad Street, Suite 900
Richmond, VA 23219
STEP 3
PART D. CERTIFICATION
I hereby authorize the RRS to change my name; documentation is attached.
I am the member
I am a Power of Attorney or guardian, and documentation is attached
Forms are processed the 15th
of each month.
THANK YOU!
Signature
Date
RRS USE ONLY
Date Processed: __________________
Reviewed By:
__________________
ID Verified:
___________________________________
Form revised April 2015
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 | www.richmondgov.com/retirement