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[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
Spouse’s Name
(if applicable):
# Dependents claimed (based on change in
status):
Children’s
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
