Mail completed form to: *290*
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Change of Address Form
This application is for members who wish to change their address that NYCERS has on file. Should you have any questions regarding this application, please contact our Call Center at 347-643-3000.
Member Number OR
First Name
Pension Number |
Last 4 Digits of SSN |
M.I. Last Name
New Address:
IN CARE OF (IF APPLICABLE)
Previous Address:
IN CARE OF (IF APPLICABLE)
If you are currently receiving monthly payments from NYCERS, check one of the following boxes only.

Continue sending my check to the bank.
OR
Cancel sending my check to the bank.
Please send my check to my new address, as listed above.
Signature of Member |
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Date |
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This form must be acknowledged before a Notary Public or Commissioner of Deeds |
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State of |
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County of |
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On this |
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day of |
2 0 |
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, personally appeared |
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before me the above named, |
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, to me known, and known to |
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true. |
If you have an official seal, affix it |
Signature of Notary Public or |
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Commissioner of Deeds |
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Official Title |
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Expiration Date of Commission |
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