name or address change form drs ms 101 (drsms101) · 2020. 4. 23. · name/address change this form...

DRS MS 101 1/20 *DRSMS101* Name/Address Change This form is for inactive members, retirees, beneficiaries, survivors and legal-order payees to use to update their names and/or addresses. 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 ꔷ Fax: 360.664.7975 Important Information Active Members: Please update your name and/or address through your employer. Address-Only Change: You can update your address online at www.drs.wa.gov/oaa or use the form below. Name Change: The name you write below must match your Social Security card. If your name has changed, please submit a copy of one of the following documents with this form: • Social Security card • Passport/passport card • Government-issued driver license or identification (ID) card • NEXUS card • Naturalization certificate • Certificate of Armed Services Record — US DD-214 Filling in Form for Someone Else: If you are filling in this form for someone, you must submit a copy of either a power-of-attorney or court-appointed guardianship document that grants you the right to make changes. You also must send in an Affidavit of Attorney in Fact form, available in the Forms section of the DRS website. Signature All information on this form is accurate and complete. Signature Date Personal Information New or Current Name (Last, First, Middle) Social Security Number Former Name, If Applicable Birthdate (mm/dd/yyyy) New or Current Mailing Address City State ZIP Email Address Phone Number Status (Check All That Apply) c Inactive or Separated Member c Retiree c Beneficiary c Survivor c Legal-Order Payee 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.

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Page 1: Name or Address Change form DRS MS 101 (drsms101) · 2020. 4. 23. · Name/Address Change This form is for inactive members, retirees, beneficiaries, survivors and legal-order payees

DRS MS 101 1/20*DRSMS101*

Name/Address ChangeThis form is for inactive members, retirees, beneficiaries, survivors and legal-order payees to use to update their names and/or addresses.

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 ꔷ Fax: 360.664.7975

Important Information

Active Members: Please update your name and/or address through your employer.

Address-Only Change: You can update your address online at www.drs.wa.gov/oaa or use the form below.

Name Change: The name you write below must match your Social Security card. If your name has changed, please submit a copy of one of the following documents with this form:

• Social Security card• Passport/passport card• Government-issued driver license or identification (ID) card• NEXUS card• Naturalization certificate• Certificate of Armed Services Record — US DD-214

Filling in Form for Someone Else: If you are filling in this form for someone, you must submit a copy of either a power-of-attorney or court-appointed guardianship document that grants you the right to make changes. You also must send in an Affidavit of Attorney in Fact form, available in the Forms section of the DRS website.

SignatureAll information on this form is accurate and complete.

Signature Date

Personal InformationNew or Current Name (Last, First, Middle) Social Security Number

Former Name, If Applicable Birthdate (mm/dd/yyyy)

New or Current Mailing Address City State ZIP

Email Address Phone Number

Status (Check All That Apply)c Inactive or Separated Member c Retiree c Beneficiary c Survivor c Legal-Order Payee

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.

http://www.drs.wa.gov/oaa

http://www.drs.wa.gov/forms/member/AffidavitofAttorneyinFact.pdf

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