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Part H Authorization Either the employer s authorized agent or the member must sign SFN 10766 to be valid. 10766 NOTICE OF CHANGE-MEMBER DATA RECORD NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM SFN 10766 Rev. 01-2014 NDPERS PO Box 1657 Bismarck North Dakota 58502-1657 701 328- 3900 1-800-803-7377 Fax 701-328-3920 MEMBER S NAME PART A Name Last First Middle Suffix NDPERS Member ID Last Four Digits of Social Security Number Date of Birth Org.

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