Name Change Form
STEP 1
Please fill out your form,
typed or printed in ink,
and remember to sign.
STEP 2
Submit your form...
STEP 3
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3P,
with a photo ID
or
...by mailing your form to:
Richmond Retirement System
730 E. Broad Street, Suite 900
Richmond, VA 23219
THANK YOU!
I hereby authorize the RRS to change my name; documentation is attached.
Signature
This form is for retirees or former
employees who would like to change
their name.
Current employees can contact the
Department of Human Resources
and log in to www.icmarc.org to
obtain a Name Change Form from
ICMA-RC, if applicable.
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
I am a Power of Attorney or guardian, and documentation is attached
I am the member
Forms are processed the 15th
of each month.
PART D. CERTIFICATION
RRS USE ONLY
Date Processed: __________________
Reviewed By: __________________
ID Verified:
___________________________________
Form revised April 2015
PART A. MEMBER INFORMATION
Phone Number
Social Security #
Mailing Address
City/State/ZIP
Email Address
PART B. OLD AND NEW NAME
OLD First Name
OLD Last Name
OLD Middle Initial
PART C. ATTACH 1 TO FORM
A marriage certificate
A divorce order
The court document named below:
NEW First Name
NEW Last Name
NEW Middle Initial
Date
