Personal Information Change Form - Lehigh University
Personal Information Change Form
Please print all information in ink.
Name:________________________________________________ LIN or SS#: ___________________
Effective Date of Change: ________________________________ Extension: ____________________
Department/Campus Address: ___________________________________________________________
Please change my personal information as indicated below:
Name: _______________________________________________________________________
(You must attach a copy of your new Social Security card to change your name.)
Home Address: ________________________________________________________________
Home Telephone Number: _______________________________________________________
Marital Status: Please provide supporting documentation i.e. marriage certificate, divorce decree, etc.
Single Married Domestic
Partnership (DP)
Widowed Divorced DP Termination
Please ADD REMOVE the following spouse/partner/dependent(s):
____________________________________________________________________________________
(Name) (Relationship) (Date of Birth) (SS#)
____________________________________________________________________________________
(Name) (Relationship) (Date of Birth) (SS#)
____________________________________________________________________________________(Name) (Relationship) (Date of Birth) (SS#)
____________________________________________________________________________________(Name) (Relationship) (Date of Birth) (SS#)
Please change my emergency contact person to:
____________________________________________________________________________________
(Name) (Phone Number) (Alternate Phone Number)
____________________________________________________________________________________
(Address)
Please send a “Request to Change Flexible Benefit Elections” form. Submission of a Request to Change Benefits Elections does not indicate approval of the requested changes. You will be notified of confirmation or denial of any changes.
____________________________________________________________________________________Signature Date
................
................
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