[Name]

CHANGE OF ADDRESS / STATUS PROCEDURES

If you have a change of address or change in status (marriage, divorce, birth, work schedule, etc.)
throughout the year you must notify the following:

Human Resources ([Name]) Payroll Processing ([Name])

Benefits Coordinator ([Name]) Time Entry Control ([Name])

You must also complete a change form for the following benefits (if applicable):

 Health, Dental and Life

 [Insurance Company Name] (LTD and STD)
 401(k) form, including a beneficiary form if you get married or divorced
 The employee is responsible for changing their address with [Retirement Plan Provider] by
logging onto the website: [Retirement Plan Provider Web Site] and follow prompts to change
address.

These forms are available in each office. Forward directly to [Benefits Coordinator Name].

Last Name: First Name: Middle Initial:

Office: Department: Position: FT/PT/Seasonal:

SSN:

ADDRESS CHANGE

New Address:

City: State: Zip:

New Home Phone #: Cell Phone #:

CHANGE IN FAMILY STATUS

From: Single Married Divorced Widowed Date of Event:

To: Single Married Divorced Widowed

Spouses Name (if applicable): # Dependents claimed (based on change in status):

Childrens Name(s) (if applicable):

CHANGE IN WORK STATUS

Full time (maintain 30 hours week)
Part-time (work AT LEAST 1560 hours annually) Part-time (less than 1560 hours annually)

I am increasing/decreasing my hours from annually to annually (which is wkly basis).

CHANGE IN EMERGENCY CONTACT

Emergency Contact: Emergency Phone:

Relationship: Address:

ADDITION OF PROFESSIONAL DESIGNATIONS

CPA, CVA, QBA, etc.: Date received: License Cert. #: Date of Cert.:

States from which certificates have been granted:

For Office Use Only:

Human Resources Benefits Administration Payroll Time Entry