REQUEST FOR CHANGE OF NAME
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: ________________________________________________________________
MAILING ADDRESS:___________________________________________________________________
___________________________________________________________________
SOCIAL SECURITY NUMBER: ___________________________________________________________
OLD NAME: _________________________________________________________________________
NEW NAME:_________________________________________________________________________
REASON FOR NAME CHANGE:
J Change in Marital Status
J
Court Order
J Religion
(Please provide marriage
(Please provide
certificate or divorce decree)
court order)
J
Other (Please specify) _____________________________________________________________
____________________________________________________________________________________
_______________________________________________
Signature of Retiree / Active Employee  vvvvvvvv
GERS-BEN112  REV 06
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