Fillable Address Change Authorization Participant Information (California)

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Address Change Authorization Participant Information (California)

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P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Address Change Authorization
Section 1
Participant Information
Please include your
first name, middle
initial and last
Participant's Full Name
name.
Social Security Number or CalPERS ID
Change Requested
Update my address for mailing my checks or direct deposit slip
Change my physical address
Change my address for mailing other information
Section 2
Please fill in your
correct mailing
address.
If you have health
coverage through
CalPERS your mailing
address cannot be a
P.O.Box
New Address Information
In Care of (if applicable)
Address
*If you are changing to
a foreign address
please provide
Province/Territory and
Country
Please include country
code if using a foreign
telephone number
Section 3
Signature and Date
are required
P.O. Box
City State Zip Code
Province/Territory* Country*
Telephone Number
Required Signature
Acknowledgement:
I am a Guardian/Conservator or have Power of Attorney for the person entitled to the allowance. (A
copy of Guardian/Conservators/Power of Attorney papers must be on file with CalPERS before an
address change will be completed.)
Signature Date (mm/dd/yyyy)
my|CalPERS 2190
Page 1 of 1
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections
20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
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Address Change Authorization Participant Information (California)

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Completed 8 March 2022

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