Employee Address and Name Change
FACULTY
Please Print
Employee Name _______________________________________________________
Colleague ID Number

Mark if Change of Name
(A copy of your updated social security card must be attached.)
New Name ___________________________________________________

Mark if Change of Address
New Address _________________________________________________________
_________________________________________________________
Telephone #
(________)________________________________________________
Effective Date of change ________________________________________________
I understand that for Social Security reporting purposes, my name must appear on KCC’s Payroll
System the same as it appears on my Social Security Card.
Signature _________________________________
Date ________________________
You will need to contact your Retirement Office directly to report name and/or address changes.
Human Resources Use Only:
Processed by: _______
Address Change
NAE
ETAX
EMER
MESSA
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_______
_______
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DATE
Name Change
NAE
_______
ETAX _______
FNM
_______
Meritain _______
BC/BS
_______
Mailroom _______
Directory _______
Date
File tab(s)
EMER
I9
IS
Registration
Web Specialist
Infrastructure
_______
_______
_______
_______
_______
_______
_______
Date