EMPLOYEE INFORMATION CHANGE FORM
EMPLOYEE INFORMATION CHANGE FORMPlease make the following change(s) in my Payroll and Personnel records:Employee Name: _______________________________________________________Employee I.D. Number: _________________________________________________ (Required. Number can be found on your pay stub.)CHANGE(S): NEW NAME:* ____________________________________________________ (copy of new Social Security card required) NEW ADDRESS:* _________________________________________________ _________________________________________________ ZIP CODE _______________________ NEW PHONE NUMBER: (H) _______________________________________ (W) ______________________________________ (C) _______________________________________ NEW EMAIL ADDRESS: ___________________________________________ This information will be utilized to contact you through the CONNECT ED System EFFECTIVE DATE OF CHANGE(S): ______________________________COMMENTS: ________________________________________________________Employee Signature: __________________________________________________*Additional forms you will need to fill out when making a NAME CHANGE:__ New W-4 (Federal) and IT-2104 (State) Withholding Forms__ Medical / Dental Form (RASHP Enrollment Form)__ Address Change Form / possible Beneficiary Change Form for:__ Retirement System (NYS Teachers’ OR Employees’)__ Life Insurance Policy*Additional form you will need to fill out when making an ADDRESS CHANGE:__ Address Change Form for:__ Retirement System (NYS Teachers’ OR Employees’) **BE SURE TO NOTIFY YOUR DEPARTMENT OF THIS CHANGE****SEND THIS (and ANY ADDITIONAL FORMS) to the HUMAN RESOURCES OFFICE**OFFICE USE ONLY: HUMAN RESOURCES ______ 11/2016 ................
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