Date: _________________________________

Mr. Theodore Wilder, Executive Secretary

Employees’ Retirement System – City of Norfolk

City Hall Building, Room 309

810 Union Street

Norfolk, VA 23510

I, ________________________________________, Soc. Sec. No.___________________________,

age____________, hereby change my address with the Employees’ Retirement System of the City of Norfolk, as follows:

Change To: Change From:

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

Tel. No.____________________________ Tel. No.___________________________

Check One:

______Continue Direct Deposit ______Stop Direct Deposit ______I Do Not Have Direct Deposit

This change is/was effective on __________________________.

____________________________________________

Member’s Signature

__________________________________________________

City of ____________________

State of ___________________

The above-named individual, _________________________________________________________, appeared before me this ________ day of ___________________________, 19_____, and I attest to his/her signature.

(SEAL) _____________________________ _________

Signature of Notary Public