Labor and Industries Pension Benefits Section PO Box 44281 Olympia WA 98504-4281
ADDRESS CHANGE REQUEST
(360) 902-5119 Effective Date NAME Please check one: Pensioner Widow/er Dependent Power of Attorney/Guardian Claim # Folio #
New Mailing Address
City
State
ZIP+4
Please provide us with the telephone number you would prefer to be contacted at: Work Telephone Number (if applicable) Home Telephone Number
Signature
Date
(PLEASE NOTE that any change of address must be received in this office no later than the 8th of the month to effect payments scheduled to be mailed to you on the 15th of the month. (This does not effect those who have direct deposit.) Should you choose, for quick arrival, you may fax your request back to the department at (360) 902-6455.
F242-107-000 address change request 06-2007