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MTA Defined Benefit Pension Plan Change of Address Form DB-PEN-001 Section 1 - Information and Instructions The purpose of this form is for Retirees to notify the MTA Business Service Center BSC of a change of address. Please return original signed and Notarized form to MTA Business Service Center Attention Pension Dept. 333 W. 34th St. 8th Floor New York NY 10001 If you have any questions please contact the BSC at 646-376-0123 or bscservice mtabsc.org. Please return original signed and Notarized form to MTA Business Service Center Attention Pension Dept. 333 W* 34th St* 8th Floor New York NY 10001 If you have any questions please contact the BSC at 646-376-0123 or bscservice mtabsc*org. Section 2 Retiree Information First Name Last Name Street Address City M. I. State Telephone Number Zip Code Social Security No DOB Section 3 Old Address Information Section 4 New Address Information Section 5 - Authorization I do hereby certify that to the best of my knowledge the above information is true and correct. Employee Signature Date Section 6 This Acknowledgement Must Be Completed by a Notary Public State of County of on this Day of personally appeared to me personally known or proved to me on the basis of satisfactory evidence to be the individual s whose name s is are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ their capacity ies and that h9s/her/their signature s on the instrument the individual s or the person upon behalf of which the individuals s acted executed the instrument. Signature Notary Public Please sign and affix stamp Business Service Center Last Revised 07/02/2012 Creation Date 087/02/2012. 333 W* 34th St* 8th Floor New York NY 10001 If you have any questions please contact the BSC at 646-376-0123 or bscservice mtabsc*org. Section 2 Retiree Information First Name Last Name Street Address City M. I. State Telephone Number Zip Code Social Security No DOB Section 3 Old Address Information Section 4 New Address Information Section 5 - Authorization I do hereby certify that to the best of my knowledge the above information is true and correct. Section 2 Retiree Information First Name Last Name Street Address City M. I. State Telephone Number Zip Code Social Security No DOB Section 3 Old Address Information Section 4 New Address Information Section 5 - Authorization I do hereby certify that to the best of my knowledge the above information is true and correct. Employee Signature Date Section 6 This Acknowledgement Must Be Completed by a Notary Public State of County of on this Day of personally appeared to me personally known or proved to me on the basis of satisfactory evidence to be the individual s whose name s is are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ their capacity ies and that h9s/her/their signature s on the instrument the individual s or the person upon behalf of which the individuals s acted executed the instrument.

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