This form is to be used to
notify the Fund Office of
any
changes to y
our contact
information.
This form Does Not
change your beneficiary. You must complete and submit a Change of Beneficiary form, if needed.
2171 East View Parkway • Conyers • Georgia • 30013-5756
Phone: 770-388-5757 or 1-866-374-0788 Fax: 678-413-4227
eMail: leanna@gfpf.org Web Site: www.gfpf.org
Georgia Firefighters' Pension Fund
Change of Address
I hereby request the Georgia Firefighters' Pension Fund to change my contact information as completed above.
REV. 12/15
____________________________________________________________
Signature of Member or
Surviving Beneficiary
__________________________________________
Date
(Please Print)
Member No: _________________ or Social Security No: _________________
Last Name: ________________________________ First: ______________________ Middle: _____________________
(Please Print)
Home/Mailing Address: _______________________________________________________________________________
City: ____
___________________________________________ State: ________________ Zip: ____________________
Phone(H): _______________________ Phone(C): ________________________ Phone(W): ______________________
Email:______________________________________________________________________________________________
(This does not change your beneficiary. You must complete and submit a Change of Beneficiary form, if needed.)
(Please Print)
Last Name: ________________________________ First: ______________________ Middle: ____________________
Home/Mailing Address: _______________________________________________________________________________
City: ______________________________________________ State: ________________ Zip: ____________________
Phone(H): _______________________ Phone(C): ________________________ Phone(W): _______________________
Email:_____________________________________________________________________________________________
Relationship: ________________________________________________________________________________________
Member Info
Member Contact Info Beneficiary Contact Info
