Fillable Benefit Information Request Form (Port of Richmond)

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Benefit Information Request Form (Port of Richmond)

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  • 10 other fields

Country of origin: US
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Benefit Information Request Form
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, for your
form to be processed, and we
will get back to you with the
information that you
requested, in the delivery
method of your choosing.
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3PM,
with a Photo ID,
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
Value of Life Insurance Policy
Proof of Prior Health Coverage
Listed Beneficiary - RRS
Survivor Option Inquiry
Copy of Tax Withholding Certificate
Federal State
Duplicate 1099-R
Copy of Annual Benefit Statement
Contribution Account Balance
PART D. CERTIFICATION
I certify that the information provided on this form is true and accurate to the best of my knowledge.
PART C. DELIVERY METHOD (CHOOSE ONE)
Member Signature Date
RRS USE ONLY
Date Processed: __________________
Reviewed By: __________________
ID Verified:
___________________________________
This form is for members of the
RRS who would like information
relating to their account(s) or
benefit(s).
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
Last Year Last 2 Years Last 3 Years
Form revised May 2015
Last 4 Years Last 5 Years
To protect your privacy, we only mail information to the verified address that we have on file.
Additionally, we require a photo ID at the time of drop-off to fax or email information (if available).
USPS First Class Mail (to the verified address that RRS has on file)
Fax: Email:
I would like to be called when this information is ready, so that I can pick it up during
walk-in hours. I understand that I will need to bring a Photo ID.
Listed Beneficiary - Life Insurance
Adtl. Requests:
For the following requests, you will receive a response from the RRS:
For the following requests, you will receive a response from a third party:
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Benefit Information Request Form (Port of Richmond)

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Completed 4 August 2020

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