Form 1c - 2012 Change Of Information Form
Download a blank fillable Form 1c - 2012 Change Of Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 1c - 2012 Change Of Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Change of Information
Form 1C – Revised 8/1/2012
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Fill in your name as currently filed with PERS and use sections 2 and 3 to submit new information before
Member/Benefit Recipient Information
–
certifying information in Section 4.
First Name: ____________________________ MI: _______ Last Name: ______________________________________ Member Benefit Recipient
Social Security No.: _______________________________________ Birth Date mm/dd/ccyy: _________________________________ Gender: M F
Check items to be updated then fill in only applicable information.
Change of Member/Benefit Recipient Information
–
Effective Date mm/dd/ccyy: __________________
To Change
New Information
____ Name
First Name: ____________________________ MI: _______ Last Name: _____________________________________________
____ Address
Mailing Address: _________________________________ City: _________________________ State: _______ Zip: ___________
____ E-Mail
________________________________________________________________________________________________________
________________________________________________________________________________ Cellular Home Work
____ Phone
________________________________________________________________________________ Cellular Home Work
____ Phone
________________________________________________________________________________ Cellular Home Work
____ Phone
Use additional Form 1C, Change of Information, if listing more than four dependent children. Information is for
Change of Family Information
–
determining statutory benefits only. Use Form 1B, Beneficiary Designation, to officially designate any and all beneficiaries. If changes to marital status are
attach a copy of the marriage, divorce, or death certificate.
marked,
Select one. Add date for last three.
Effective Date mm/dd/ccyy: ________________
Single
Married
Divorced
Widowed
Marital Status
–
Birth Date mm/dd/ccyy
Wedding Date mm/dd/ccyy
Spouse’s Full Name
Social Security No.
Gender
_______________________ M F
_____________________________________ ____________________________ _______________________
Dependent Child’s Full Name – Up to age
Birth Date mm/dd/ccyy
Social Security No.
Relationship
Gender
19, or 23 if unmarried and a full-time student
_______________________ M F
_____________________________________ ____________________________ _______________________
_______________________ M F
_____________________________________ ____________________________ _______________________
_______________________ M F
_____________________________________ ____________________________ _______________________
_______________________ M F
_____________________________________ ____________________________ _______________________
Active members should sign and submit form to employer for completion of Section 5. Employers will be
Member/Benefit Recipient Certification
–
responsible for submitting completed form to PERS, if necessary. Inactive members and benefit recipients should sign and submit form directly to PERS,
as Section 5 is not applicable to these individuals.
If an authorized representative signs this form, attach a copy of the durable power of attorney,
conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
Member/Benefit Recipient‘s Signature: ________________________________________________________ Date mm/dd/ccyy:______________________
This section must be completed by an authorized employer representative, not the member. Employer certification of name
Employer Certification
–
change is required for active members to ensure consistency in the name used for reporting PERS, Social Security, and W-2 wage information. All
employee name and address changes must be entered into WEB-ERS. Completion of Section 5 and submission to PERS by employers is only
necessary when changes are being made to employee phone number(s), e-mail, marital status, or family information.
Employer Name: ____________________________________________________________ Employer No.: _________________ - __________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
As employer representative, I certify that the name change information provided above is consistent with the active member’s name used on the employer’s
records for reporting PERS, Social Security, and W-2 wage information.
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005
800.444.7377
601.359.3589
601.359.5262, fax
Reset Form
Print
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business