CHANGE OF ADDRESS FORM For Retirees PERSONAL INFORMATION ...

Montana Public Employee Retirement Administration

PO Box 200131 ? Helena MT 59620-0131

(406) 444-3154 ? Toll Free (877) 275-7372



CHANGE OF ADDRESS

Please print

For Retirees

RETIREE INFORMATION

Last Name

First Name, MI

Last 4 SSN

Date of Birth

Retirement Number (leave blank if unknown)

Phone Number

Email Address

PREVIOUS ADDRESS

Mailing Address

City

State

Zip Code

NEW ADDRESS

Mailing Address

City

State

Zip Code

Please notify us of any change in your mailing address, even if you receive your checks by direct

deposit. Having your current mailing address on file ensures that you will receive year-end tax

statements and other important correspondence about your benefits. If anyone other than the

member or benefit recipient signs this form, legal documentation giving them the authority to do

so (such as a power of attorney) must be attached to this form.

Cancel Direct Deposit?

? Yes ? No

If you wish to change your direct deposit, please visit our website at

for a Direct Deposit form.

SIGNATURE AND DATE (required)

Signature

Date

Rev. 03/2024

MBS-0004

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