Fillable Health & Welfare Fund Change of Address Form

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Health & Welfare Fund Change of Address Form

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The Health & Welfare Fund Change of Address Form form is 2 pages long and contains:

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  • 2 check-boxes
  • 44 other fields

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File type: PDF

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Page 1 of 2 –
Rev. 201906
Health & Welfare Fund
Police Benevolent Association of the City of New York, Inc.
125 Broad Street, 11
t
h
Floor
New York, NY 10004
Phone: (212) 349-7560
Fax: (212) 437-9480
www.nycpba.org
Instructions:
Please use this form to update your mailing address. Be sure to fill out this form both accurately and
completely, as it is essential that the PBA Funds Office has your most up to date information to
administer your Health and Welfare benefits to you and your eligible dependents.
Please be aware that you must also update your information with the City of New York separately. The
PBA Funds Office and the City of New York do not share or exchange any of your information.
Member’s Information:
Last 4 Digits - SSN
Tax ID
Last Name
First Name
New Address:
Address
Apt
City
State
Zip Code
Phone Number
Email Address
Effective Date Of Change:
Do you have eligible dependents who do not live with you?
If you have eligible dependents who do not currently live with you, please complete the “Dependent(s)
Information:” section on page 2. If your eligible dependents live with you please disregard page 2 of this
form.
Signature:
Date
Month
Day
Year
/ /
Yes No
Change of Address Form
Demographics
Page 2 of 2 –
Rev. 201906
Dependent(s) Information:
Dependent’s First Name Last Name:
Address
Apt
City
State
Zip Code
Phone Number
Dependent’s First Name Last Name:
Address
Apt
City
State
Zip Code
Phone Number
Dependent’s First Name Last Name:
Address
Apt
City
State
Zip Code
Phone Number
Dependent’s First Name Last Name:
Address
Apt
City
State
Zip Code
Phone Number
For Office Use Only:
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Health & Welfare Fund Change of Address Form

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Completed 14 April 2021

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