09/12
BRENTWOOD PUBLIC SCHOOLS
EMPLOYEE STATUS CHANGE
NAME:_______________________________________________________BLDG.___________________________
LAST
FIRST
EMPLOYEE#_________________POSITION/TITLE___________________________________________________
NEW NAME*
PLEASE PRINT:
LAST
FIRST
REASON:
MARRIAGE, COURT ORDER, ETC.
*COPY OF SOCIAL SECURITY CARD WITH NEW NAME MUST BE INCLUDED FOR NAME CHANGE
NEW ADDRESS/TELEPHONE NUMBER**
STREET:
TELEPHONE #:
TOWN/STATE/ZIP:
**In order to process an address change, you MUST check Yes or No to the following questions:
Are you a resident of New York City*?..... _________Yes
Are you a resident of Yonkers*?................ __________ Yes
__________No
__________No
*NYC AND YONKERS SUBJECT TO LOCAL TAX WITHHOLDING
_____________
MARITAL STATUS: FROM: (Circle One)
TO: (Circle One)
SINGLE OR MARRIED
SINGLE OR MARRIED
______
TAXES:
NOTE: Attach “Employees Withholding Exemption Certificate, Federal FORM W 4” and “NYS FORM IT2104” with
new name, change in tax residency and/or change of exemptions.
BENEFITS:
PLEASE SEND APPROPRIATE FORMS AS I WISH TO UPDATE THE FOLLOWING BENEFITS:
__________COVERED FAMILY DENTAL
__________LIFE INSURANCE BENEFICIARY
__________COVERED FAMILY HEATH
__________ RETIREMENT SYSTEM BENEFICIARY
THE ABOVE CHANGE (S) IS (ARE) TO BE EFFECTIVE AS OF:
SIGNATURE
DATE
PLEASE RETURN ORIGINAL TO THE PAYROLL DEPARTMENT
__
PAYROLL
PAYROLL - AFTER INITIALING, PLEASE ROUTE TO:
BUSINESS OFFICE
____________
HUMAN RESOURCES
____________