PAYROLL OFFICE
                                      California University of Pennsylvania
                                       250 University Avenue – Box #10
                                 California, PA 15419 (724) 938-4426

Employee Name:                                                                    Personnel #:

                    PART I: Change of Address / Local (Wage) Tax
New Address:

County:                                                  School District:
Municipality:                                                 Township            Boro          City

Telephone #:                                                                   Unlisted? Yes / No

 This is my permanent address.
 This is my mailing address. (Complete another form to change permanent address if necessary).
 Please check here if you currently have a payroll deduction for U.S. savings bond(s) as
    we must change the name/address on your bond.
                                    PART II: Change of Name
               (Please print name exactly as it appears on your social security card.)
New Name:
                                First                    Middle Initial                       Last

                         PART III: Change of Emergency Contact
New Emergency Contact Name:

New Address:

New Phone Numbers:

                                PART IV: Signature and Date

SIGNATURE                                                                           DATE
How you complete PART I will determine your taxing jurisdiction. You should enter the actual city, borough,
or township, which you consider to be your “permanent residence.” Do not use a post office location through
which your mail is received. “Permanent residence” is the place (city, borough, or township) where you have
voluntarily located yourself with the intention of making it your home and the place you return to whenever

The Payroll Office should be contacted if you have questions. The completed questionnaire is to be returned
to the Payroll Office. Changes to permanent residences should be reported promptly to the Payroll Office.

NOTE: We will notify the following campus offices of the above change(s): President, Personnel, and Provost.

                                  FOR PAYROLL OFFICE USES ONLY
PERSONNEL NUMBER:                                                      INPUT DATE:
RESIDENCE WAGE TAX CODE:                                               INPUT BY (Initials):

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