Personal Data and Change Form
NEW EMPLOYEES MUST COMPLETE THIS FORM IN ITS ENTIRETY. If making changes to personal data,
ONLY complete the name and changes required.
LEGAL NAME: Legal name must match that as recorded by the Social Security Administration (SSA). If your name is not correct with the SSA, you
MUST update your records with that office. If making a change, it must be verified in the human resources office. Legal documentation to
verify the change is required. Submit a copy of social security card, marriage certificate, or official court document granting name change.
LEGAL NAME:
Last
First
MAIDEN NAME:
Middle
Suffix
NICKNAME:
E-MAIL ADDRESS:
SOCIAL SECURITY NUMBER:
-
-
MARITAL STATUS/DATE OF BIRTH CHANGE: If making a change to Date of Birth, you must provide documentation that
shows your correct Date of Birth. Please remember that if you change is to Marital Status, you may also need or want to make a
corresponding change to your benefit coverages (for eligible employees).
MARITAL STATUS:
Single
Married
DATE OF BIRTH:
/
/
ADDRESS/PHONE CHANGE
HOME ADDRESS: This is your legal residence.
Street
City
State
Zip
MAILING ADDRESS: This address is used for mailing payroll checks, tax information, and tax reporting purposes. All benefit
enrollment information (for eligible employees) will be sent to this address.
Street
PHONE
(
City
)
-
State
(
Home
Zip
)
Cell
IDENTIFICATION DATA
Birthplace (County, State)
Driver License Number
State Issued
PRINT NAME:
EMPLOYEE SIGNATURE
DATE
HUMAN RESOURCES DEPA RTMENT
Expiration Date