Fillable 153W-Information-Change-Request 459-153 Member-Alternate Payee Change Request.indd

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153W-Information-Change-Request 459-153 Member-Alternate Payee Change Request.indd

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Information Change Request
Section A: Applicant information
(Type or print clearly in dark ink. Illegible forms may be returned to applicant. This could delay your request.)
*Providing your Social Security number (SSN) is voluntary. It will be used for confirmation purposes. If you choose not to supply your SSN, it may take PERS staff longer to process your form.
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling toll-free 888-320-7377 or TTY 503-603-7766.
Form #459-153 SL3 (7/26/2019) IIM Code: 2246
This form is for all PERS programs. Call or visit our website if this is not the form you need.
Check any boxes that apply, and provide the requested information. Attach the requested proof as needed.
q Change my email address to ____________________________________________________________.
If you are working for a PERS-covered employer, you must submit the following changes through
your employer(s).
q Change my Social Security number from ______________________ to ___________________________.
I have attached a photocopy of proof of my correct Social Security number (e.g., Social Security card, Social Security statement, etc).
q Change my name from _________________________________to _______________________________.
I have attached a copy of a legal document showing my current legal name (e.g., driver’s license, divorce decree, court order
, etc).
q As of ________________________________, my address will be:
Section B: Information change
Section D: Applicant signature (Required)
Date
Signature (do not print)
q Continue to send my benefits directly to my financial institution.
(This address change is only for PERS’ use in contacting me.)
q Use this address change for mailing my monthly check to me.
q Stop my direct deposit, and mail my check to me.
q Send a duplicate copy of my 1099-R for ________ q PERS/OPSRP q IAP.
(year)
Street/post office box Apartment no./space no.
City State ZIP
Section C: Benet recipient only
First name MI Last name PERS ID
Home phone number Work phone number Cell phone number Social Security number*
Email
Note: Address will be edited to conform with USPS standards.
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Print Form
Clear Fields
Verification of Age or Identity
Photocopies of birth-date documents and, if applicable, beneficiary birth-date documents are required before
benefits are paid. We will not accept documents that are incomplete, appear to be altered, or are difficult to
read. If your documents are not accepted, you will need to submit new photocopies. Please include your
PERS ID or Social Security number* on all documents submitted, including beneficiary forms.
If it is impossible for you to furnish the proof required in Group 1 or 2, write to PERS with a full explanation.
Since the documents submitted cannot be returned, we suggest using photocopies. If it is illegal to copy a
document, bring it in, and PERS will verify the birth information.
Be sure to put the PERS member’s Social Security number on all documents so they are properly recorded.
Group 2
Two items in this group from different sources are
sufficient if age or birth date is shown.
Any TWO of these:
Example: One child’s birth certicate and one driver’s license.
Any ONE of these:
• A notarized afdavit by an older, immediate family
member in a position to know the birth date (e.g.,
father, mother, etc.)
• Certicate of military record
• Marriage record (Record must show your age or
date of birth at time of marriage.)
• Copy of Oregon driver’s license or ID card if issued before
February 4, 2008, or any other state’s license or ID card
issued at any time
• County voter registration (Must show your age or date
of birth; do not send in your precinct card.)
• Copy of child’s birth certicate if it shows age of parents
• Social Security record (Record must be displayed on
an estimate of benets or screen print from the Social
Security ofce. Document must be dated within last
12 months.)
• Military ID (military record DD214)
• Concealed weapons permit
Reference: OAR 459-013-0040
FS 459-029 (2/14/2018)
*Providing your Social Security number (SSN) is voluntary. It will be used for confirmation purposes. Failure to supply your SSN may delay the processing of this form.
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Group 1
If one item in this group is furnished showing birth
dates, no further evidence of age is needed.
Any ONE of these:
• Copy of Oregon driver’s license or ID card if issued on
or after February 4, 2008
• Birth verication issued by state, county, or country
(Documents issued by foreign governments in a
language other than English need to include a
translation into English certied by a notary public,
public agency, or other public ofcial.)
• American Indian Reservation Age Verication
• Infant baptism certicate
• Hospital birth certicate (if signed by attending
physician or issued by state)
• Passport (current or expired)
• School-age record
• Naturalization or citizenship papers
• Family Bible record (If this record is furnished,
include the following information certied by a
notary public or other public ofcial: copy of all
family record entries in the Bible referring to
applicant and parents, brothers, and sisters; Bible
publication date or apparent age of Bible; when birth
date was entered and by whom.)
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Completed 18 May 2020

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