ADDCHG

(Rev. 8.97)

RETIREMENT SYSTEMS OF ALABAMA

ADDRESS CHANGE NOTIFICATION

Retired Members: This form is for HOME ADDRESS ONLY and is NOT to be used for DIRECT DEPOSIT Bank addresses.

FORM MUST BE SIGNED

Retired Members Only:

TO BE VALID

Check below if applicable

_____    I receive more than one monthly payment from RSA.

EFFECTIVE DATE

_____    I wish to receive a form to request setup or change Direct Deposit to my bank.

OF NEW ADDRESS _____/_____/_____

MEMBERSHIP

STATUS

EMPLOYEES

ACTIVE

X

SSAN  _____-_____-_______

JUDICIAL

INACTIVE

PLEASE PRINT

Social Security Account number

TEACHERS

X

RETIRED

EMPLOYER  _____________

RSA-1

BENEFICIARY

(Active Members Only)

PEIRAF

RECEIVING

PEEHIP

X

NAME  _________________________________________________________________

OLD       ADDRESS

STREET ________________________________________________________

CITY  ________________________________STATE_____ZIP________-____

NEW       ADDRESS

STREET ________________________________________________________

CITY  ________________________________STATE_____ZIP________-____

SIGNATURE ______________________________________  DATE SIGNED _____/_____/_________

PLEASE COMPLETE FORM, SIGN, AND RETURN TO BOARD OF EDUCATION

P.O. BOX 578, ONEONTA, AL 35121       ATTN:  ROBBIE BEASON