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  • Information Release Authorization form DRS MS 249 (drsms249) · Information Release Authorization This form is for members to use to authorize the release of account information to
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Signature The information on this form is accurate. I understand that the individual named in the Release Information section must provide my Social Security number before receiving any of my account information. This authorization remains in effect until DRS receives a written document revoking the authorization. Signature Date Release Information Third-Party Name Email Address Phone Number Information to Release to Third-Party Person or Entity Named Above (check one) c General account information, including my balance or benefit amount c All account information, including both general account information and any medical documentation in my member file c Account information for a divorce: Date of Marriage ______________________ Date of Separation ________________________ DRS MS 249 9/20 *DRSMS249* Information Release Authorization This form is for members to use to authorize the release of account information to a third party. Send completed form to: Department of Retirement Systems PO Box 48380 ꔷ Olympia, WA 98504-8380 www.drs.wa.gov ꔷ 800.547.6657 360.664.7000 ꔷ TTY: 711 Member Information Name (Last, First, Middle) Social Security Number Email Address Phone Number Retirement System and/or Program c Apply to All My Retirement Plans/Programs c Washington State Patrol Retirement System (WSPRS) c Public Employees’ Retirement System (PERS) c Law Enforcement Officers’ and Fire Fighters’ Retirement System (LEOFF) c Teachers’ Retirement System (TRS) c Public Safety Employees’ Retirement System (PSERS) c School Employees’ Retirement System (SERS) c Judicial Retirement System (JRS) c Deferred Compensation Program (DCP) c Judicial Retirement Account (JRA) Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109. Length of Time This Form Will be in Effect If you don’t make a selection, this Information Release Authorization form will be valid for 90 days from the date signed (check one) c The release of information on this form is valid for 90 days from the signed date below c The release of information on this form is valid until ________________________

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Page 1: Information Release Authorization form DRS MS 249 (drsms249) · Information Release Authorization This form is for members to use to authorize the release of account information to

SignatureThe information on this form is accurate. I understand that the individual named in the Release Information section must provide my Social Security number before receiving any of my account information. This authorization remains in effect until DRS receives a written document revoking the authorization.

Signature Date

Release InformationThird-Party Name

Email Address Phone Number

Information to Release to Third-Party Person or Entity Named Above (check one)c General account information, including my balance or benefit amount

c All account information, including both general account information and any medical documentation in my member file

c Account information for a divorce: Date of Marriage ______________________ Date of Separation ________________________

DRS MS 249 9/20*DRSMS249*

Information Release AuthorizationThis form is for members to use to authorize the release of account information to a third party.

Send completed form to:Department of Retirement SystemsPO Box 48380 ꔷ Olympia, WA 98504-8380

www.drs.wa.gov ꔷ 800.547.6657360.664.7000 ꔷ TTY: 711

Member InformationName (Last, First, Middle) Social Security Number

Email Address Phone Number

Retirement System and/or Programc Apply to All My Retirement Plans/Programs c Washington State Patrol Retirement System (WSPRS)c Public Employees’ Retirement System (PERS) c Law Enforcement Officers’ and Fire Fighters’ Retirement System (LEOFF)c Teachers’ Retirement System (TRS) c Public Safety Employees’ Retirement System (PSERS)c School Employees’ Retirement System (SERS) c Judicial Retirement System (JRS)c Deferred Compensation Program (DCP) c Judicial Retirement Account (JRA)

Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.

Length of Time This Form Will be in EffectIf you don’t make a selection, this Information Release Authorization form will be valid for 90 days from the date signed (check one)

c The release of information on this form is valid for 90 days from the signed date below

c The release of information on this form is valid until ________________________

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