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Address/Name Change Form - Connecticut

AddNameChg (Rev. 122617)CT TEACHERS RETIREMENT BOARD 765 ASYLUM AVENUE 2ND FLOOR HARTFORD, CT 06105-2822 An Affirmative Action/Equal Opportunity Employer Toll-Free 1-800-504-1102 (860) 241-8400 Fax (860) 241-9295 Address/Name Change form THIS form IS FOR RETIRED, INACTIVE AND ACTIVE STATE EMPLOYEE MEMBERS; SPOUSES OF DECEASED MEMBERS; AND FORMER SPOUSES OF RETIRED MEMBERS. ACTIVE MEMBERS MUST SUBMIT ALL DEMOGRAPHIC CHANGES/CORRECTIONS DIRECTLY TO THEIR EMPLOYER, WHO WILL THEN TRANSMIT THE UPDATED INFORMATION VIA THEIR NEXT MONTHLY TRANSMITTAL TO CTRB. INSTRUCTIONS: Please type or print clearly and check all boxes that apply.

Check here if the new address is a facility (such as a Nursing Home or Rehabilitation Center) which requires the resident to obtain prescription medicine through the facility’s pharmacy so that the resident cannot do so via mail order.

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STATE OF CONNECTICUT - OFFICE OF POLICY AND …

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