HPR Change of Address Form

Heating, Piping and Refrigeration Medical and Pension Funds

Steamfitters Local Union 602 Retirement Savings Plan

Mailing Address: PO Box 21427 Eagan, MN 55121 • Phone: (410) 444-3756 or (800) 618-2879 • Fax: (240) 303-2484 • Website: HPRBenefitFunds.com

Administered by Welfare & Pension Administration Service, Inc.

CHANGE OF ADDRESS FORM
Please use this form to change your address and/or telephone number. If this was mailed to your new address, we can only permanently update our records with your written request to change your address that is signed by you as the member of the Local Union.
Member Name*

First NameMiddle InitialLast Name
Form Name
(Old) Former Address
Street Address*
Street Separator
City*
City Separator
State*
State Separator
Zip Code*
Form Address Field
Former Phone Number*
Please enter a valid phone number.
(New) Current Address
Street Address*
Street Separator
City*
City Separator
State*
State Separator
Zip Code*
Form 1 Address Field
Home Phone Number*
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Only the Member of the Local Union may request that their address be changed for the Benefit Funds. The request must be submitted in writing and signed by the Member. This request may also be faxed to the number above or emailed to eligibility@wpas-inc.com.

I certify, under penalties of perjury, the signature below is that of the Local Union Member whose name appears above.

By affixing my signature hereto, I hereby certify that this change of address form is true and correct of my own knowledge. I hereby acknowledge that this Change of Address Form will be relied upon by the Funds in compliance with its reporting requirements established pursuant to federal law. I further certify that the signature provided on this form is the signature of the participant referenced above and acknowledge that any falsification of this document will be subject to all civil and criminal penalties available at law.
Member Signature*
Date

MonthDayYear
Date
Fund ID
Should be Empty:

Heating, Piping and Refrigeration Medical and Pension Funds

Steamfitters Local Union 602 Retirement Savings Plan

CHANGE OF ADDRESS FORM

(Old) Former Address

(New) Current Address