Rev.12/10
RRS67
M.I.
PART C: AUTHORIZATION
Maiden Name (if applicable)
Agency Previously Employed By:
Job Title:Location:
Member's Signature: Date:
Street Address:
Zip Code:State:City:
Date of Birth: Phone Number: E-mail Address:
As an active member of the Richmond Retirement System (RRS) and an inactive vested member of the
participating retirement system selected above, I hereby authorize my former employer's retirement system to
release information to the RRS regarding my vested benefits as required under the terms of portability between
the two retirement systems.
please type or print in ink
ACTIVE EMPLOYEE RELEASE
AUTHORIZATION FOR
PORTABILITY FORM
First Name:Last Name:
PART A: AUTHORIZED RETIREMENT SYSTEM (check applicable retirement system)
Newport News Employees' Retirement Fund
Norfolk Employees' Retirement System
Virginia Retirement System
PART B: EMPLOYEE INFORMATION
SSN:
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
