Retiree Change of Address Form

Retiree Change of Address Form

This form is used to update your address for WSSC Water insurance coverage and for retirement records. We will notify your benefit plans (health, dental and/or vision – if applicable) of your new address. If you have a WSSC Credit Union account, you must contact them directly.
Retiree Name

First NameLast Name
Old Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Effective Date of New Address
Please return the completed form at your earliest convenience to:
WSSC Water Human Resources Office, Benefits Division,
14501 Sweitzer Lane, Laurel, MD 20707 or fax 301-206-8713
Date

MonthDayYear
Signature
Should be Empty: