RETIREE CHANGE IN NAME/ADDRESS FORM
Fulton County Retirement System
Department of Finance
141 Pryor Street, Suite 7001
Atlanta, GA 30303
Pension Office: (404) 612-7606 Fax: (404) 612-1312
Email: pensionunit@fultoncountyga.gov
Retiree Information
Print Legal Name:
_____________________________________ Soc. Sec. #____________________
Address:
Email Address:
___________________________________________________________________
_________________________________________________________________________
NOTE: To change your name/address, please complete the appropriate section:
Is Georgia your legal State of Residence?
( ) Yes
( ) No**
Address Change
Address Line 1: ________________________________________________________
Address Line 2:
________________________________________________________
City:
________________________________________________________
Zip Code:
Telephone Number:
( )
_________________
Is your mailing address the same as home address? :
( ) Yes
( ) No
**If Georgia is not your legal address, you may consider discontinuing your State Tax deduction
by submitting the appropriate form. **
Name Change
To:
First Name:
___________________________________________________
Middle Name:
___________________________________________________
Last Name:
___________________________________________________
Suffix:
___________________________________________________
Effective Date:
___________________________
Note: Please attach a completed Tax Withholding form with a name change.
Information on this form will override any information that was submitted earlier:
_______________________________________________ ___________________
Signature Date