REQUEST FOR CHANGE OF ADDRESS
PLEASE PRINT
J ACTIVE
DATE_________—__________—_________________       
(mm)         (dd)               (yyyy)
J
RETIRED
NAME: _____________________________________________________________________________
(First Name)                    (Middle Initial)                 (Last Name)
DATE OF BIRTH: _________—__________—_________________          
(mm)         (dd)               (yyyy)
TELEPHONE NUMBER: ________________________________________________________________
SOCIAL SECURITY NUMBER: ___________________________________________________________
OLD ADDRESS:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
NEW ADDRESS: _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
EFFECTIVE DATE OF ADDRESS CHANGE:  _________—__________—_________________           
(mm)            (dd)                  (yyyy)
_______________________________________________
Signature of Retiree / Active Employee  
_______________________________________________
Signature of Power of Attorney
(If you are completing this form as a Power of Attorney or Guardian
for a retiree or beneficiary, please attach a copy of your Power of
Attorney or Guardianship Award.) v
vvvvvvvvv
GERS-BEN113 REV 06
Please allow 5-10 business days for
this change to take effect.
GOVERNMENT EMPLOYEES RETIREMENT SYSTEM
3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499
3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497