Name Change Notice
RS 5483
(Rev. 2/11)
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.
Registration Number
Old Name
Last Name First Name M.I.
New Name
Last Name First Name M.I.
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 administr
ation of the Retirement System.
Telephone Number
Reason for Name Change (Fill in one circle):
Change in Marital Status Court Order
(Please provide
Court Order)
Religious
(Please provide
Court Order)
Other (Please specify)__________________
Member Signature
Please sign with new name
________________________________________________ Date ______________________________
RECEIVED
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 rec
ords 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) 474-8482.
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