Authorization to Release Information to a Third Party
PART A. MEMBER INFORMATION
Name
Phone Number
Social Security #
Mailing Address
City/State/ZIP
Email Address
STEP 1
Please fill out your form,
typed or printed in ink,
and remember to sign.
STEP 2
Submit your form...
STEP 3
Wait 5 business days, from
the date of receipt, and we
will send the information that
you requested to the business
indicated on this form.
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3PM
or
...by mailing your form to:
Richmond Retirement System
730 E. Broad Street, Suite 900
Richmond, VA 23219
THANK YOU!
PART B. TYPE OF REQUEST
Monthly Pension Verification Proof of Prior Health Coverage
I certify that the information on this form is true and accurate to the best of my knowledge, and I
understand that this authorization is valid only for the single purpose described here and cannot be
applied beyond the criteria outlined in this document.
PART C. THIRD PARTY INFORMATION
Witness Signature
RRS USE ONLY
Date Processed: __________________
Reviewed By: __________________
Other:
This form is for members of the
RRS who would like information
relating to their account(s) or
benefit(s) sent to a third party.
This information is often
requested by mortgage lenders
and retirement communities.
DIRECTIONS
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 | www.richmondgov.com/retirement
Form revised May 2015
Name of Business
Phone Number
DELIVERY METHOD, (CHOOSE ONE):
Mail
Fax
Email
PART C. CERTIFICATION
Purpose of
authorization (please
describe the reason):
Printed Name Date
Member Signature Printed Name Date
