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Change of Address Form
Last Revision Date: May 2015
BOSTON RETIREMENT BOARD
Boston City Hall, Room 816
Boston, MA 02201
617-635-4311
Date: ___________________________
Name: __________________________________________________________________
SBRB Member ID #: _________________________
Previous Address:
_______________________________________________________________________________________
(Street Address)
_______________________________________________________________________________________
(City/Town) (State/Zip Code)
New Address:
_______________________________________________________________________________________
(Street Address)
_______________________________________________________________________________________
(City/Town) (State/Zip Code)
Phone #: __________________________________ E-Mail: ______________________________________
___________________________________________________________ ___________________________
(Signature) (Date)
BM02
