Retirement Benefits Record Verification Request Form
Use this form to request verification of retirement benefits records. Please provide only the information needed to identify the record and route your request.
Requester Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Email
*
example@example.com
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Retirement Record Details
Retirement benefits provider or plan name
*
Benefit type or record type requested
*
Please Select
Pension
Annuity
Retirement Savings
Survivor Benefit
Disability Benefit
Other
Retirement account or member reference (if available)
Period covered for verification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Verification Request Details
Reason for Verification
*
Please Select
Loan application
Employment verification
Personal records review
Retirement planning
Legal/estate matter
Other
Preferred Delivery Method
*
Email
Mail
Phone
Fax
Other
Special Instructions or Notes
Submit Request
Should be Empty: