UMWA HEALTH AND RETIREMENT FUNDS CALL CENTER
2121 K Street, Suite 350 Washington, DC 20037 Telephone: (800) 291-1425
Change of Address Request
Effective October 1, 2003, all address changes must be requested in writing and signed by the miner/widow or the legal representative. Please complete this form and return it to:
UMWA Health and Retirement Funds
Attn: Call Center
2121 K Street, NW Suite 350
Washington, DC 20037
Please print clearly and provide all information requested.
Mineworker/Widow Name: _______________________________________________________
(Last, First, Middle)
Social Security Number: _________-_______-___________
Telephone Number: (________)__________-____________
List All dependents currently living with you:_________________________________________
______________________________________________________________________________
Current Address:
Street Address: _________________________________________________________________
City or Town, State and Zip Code: _________________________________________________
Old Address:
Street Address: _________________________________________________________________
City or Town, State and Zip Code: _________________________________________________
Signature: __________________________________________________Date: ______________
∙If signing for a beneficiary, you must include legal proof of your power of attorney or guardianship status or relationship.
∙If witnessing a beneficiary's mark, write out both the full name of the beneficiary for whom you are witnessing and your full name.
∙If the beneficiary is unable to make a mark, and has not granted you power of attorney or guardianship, please describe the circumstances on the back and provide your telephone number.
