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Fillable Nycers F291 Form in PDF

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Changing your name is a significant step in one’s life, and for members of the New York City Employees Retirement System (NYCERS), the process involves completing the F291 form. This form serves as an official affidavit for individuals wishing to update their name on NYCERS records. To ensure a smooth transition, applicants must provide valid proof of their name change, which can include documents such as a court order, a marriage certificate, or divorce papers. The F291 form requires personal information, including the member's name, contact details, and either their member number or pension number. Additionally, the form must be signed and notarized, confirming the authenticity of the request. For those who may have questions during this process, NYCERS offers support through their Call Center, making it easier for members to navigate the requirements. Understanding the importance of this form can help individuals take the necessary steps toward updating their records efficiently.

Preview - Nycers F291 Form

If you have an official seal, affix it

NYCERS USE ONLY

F291

 

*291*

Name Change Affidavit

This application is for members who wish to change their name that NYCERS has on file. It is important to provide proof of name change, such as a court order, a copy of a marriage certificate or divorce papers, in order for your application to be processed. Should you have any questions regarding this application, please contact our Call Center at 347-643-3000.

Member Number

OR

Pension Number

 

Last 4 Digits of SSN

Daytime Phone

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

First Name

 

 

M.I.

Last Name

 

 

 

 

 

 

 

 

 

 

in Care of (if applicable)

 

 

 

 

 

Address

 

Apt. Number

 

 

 

 

 

 

City

State

 

Zip Code

 

 

 

 

 

 

To NYCERS

I, the undersigned, am employed in the Department of _________________________________ or retired from service on

[MM/DD/YYYY]

/ /

I request that my name be changed on NYCERS records from:

First Name

 

 

 

M.I.

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

M.I.

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Member

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This form must be acknowledged before a Notary Public or Commissioner of Deeds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of

 

County of

 

 

 

On this

 

day of

 

 

2 0

 

, personally appeared

before me the above named,

 

 

 

 

 

 

, 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.

Signature of Notary Public or Commissioner of Deeds

Official Title

Expiration Date of Commission

Sign this form and have it notarized, THIS PAGE

R06/30/11

Page 1 of 1
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Form Characteristics

Fact Name Description
Purpose The F291 form is used by NYCERS members to request a change of name in their official records.
Proof Required Applicants must provide proof of their name change, such as a court order, marriage certificate, or divorce papers.
Contact Information For questions regarding the form, members can contact NYCERS at 347-643-3000.
Notarization Requirement The form must be signed in the presence of a Notary Public or Commissioner of Deeds for validation.
Member Identification Members are required to provide their Member Number or Pension Number and the last four digits of their Social Security Number.
Governing Law This form is governed by New York State law regarding pension and retirement systems.
Version Date The current version of the form is noted as R06/30/11, indicating its last update date.
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