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Change of
Address Form
For Active Members Only (not retirees)
RS 5512
(Rev. 11/12)
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
PLEASE PRINT CLEARLY USING CAPITAL LETTERS. USE ONLY BLUE OR BLACK INK. STAY WITHIN BOXES.
LEAVE BLANK BOXES BETWEEN WORDS AND NUMBERS.
Registration Number (if known)
Last 4 Digits of
Social Security Number*
*SOCIAL SECURITY DISCLOSURE REQUIREMENT
In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to Sections 11, 31, 34 and
334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.
Maiden or Other Name Used Date of Birth
Month Day Year
Last Name First Name M.I.
Old Address Information:
Street Address
City State Zip Code
New Address Information:
Street Address 1
Street Address 2
City State Zip Code
Daytime Telephone Number
E-mail Address
Signature
This form cannot be processed without your signature.
Date
Month Day Year
Mail this completed form to:
New York State and Local Retirement System
Member & Employer Services
Registration – Mail Drop 5-6
110 State Street
Albany NY 12244
( )
PERSONAL PRIVACY PROTECTION LAW
In accordance with the Personal Privacy Law you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain records.
The records are necessary to determine eligibility for and to calculate benefits. Failure to provide information may result in the failure to pay benefits. The System may provide certain
information to participating employers. The official responsible for maintaining these records is the Director of Member and Employer Services, New York State and Local Retirement
Systems, Albany, NY 12244; telephone number (518) 474-3524.
RECEIVED
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