ORS Name and/or Address Change Request

Retirement (ORS)

Member information

Your details as the retirement system holds them now.

Use this form to change your name and/or address. Note: if you currently receive a pension payment by mail, this change may not affect your next pension. Your change(s) will become effective the month after ORS receives your request.

Member's last name

First name

M.I.

Member IDEnter your ORS member ID. Do not enter a Social Security number here — if you do not have your member ID, leave this blank and write it on the printed form.

Date of birth

Mailing address

City

State

ZIP code

Daytime phone number

What are you changing?

Change requested

Name changeAddress change

Name change

If you are changing your name, please enter your new name here.

Please provide legal documentation of your name change, such as a copy of a marriage certificate or Social Security card, with the signed form.

New last name

First name

M.I.

Address change

If you are changing your address, please enter your new address here.

Mailing address

Telephone

City

State

ZIP

Effective date of change

Certification

This form must be signed before it can be processed. If a member is unable to sign, the endorser must enclose a copy of his or her authorization of guardianship, power of attorney, or conservatorship. The signature line is left blank for you to sign by hand.

I understand I must print and sign this form before sending it to ORS.

Date

Your email addressUsed only to send you a copy of this request.