MONTEBELLO UNIFIED SCHOOL DISTRICT
CHANGE OF NAME / ADDRESS / TELEPHONE
SOCIAL SECURITY NUMBER _______________________________________________________________________ NAME: From ___________________________________________________________________________________
LAST FIRST MIDDLE INITIAL
To ___________________________________________________________________________________
(LN) (FN) (MI)
SITE: _________________________________________ NEW ADDRESS (AD)
POSITION: ____________________________________
_____________________________________________________________________________ _____________________________________________________________________________
NEW TELEPHONE NO. (DS) (____________) (TL) _____________________________________________________ ____________________________________
EFFECTIVE DATE
_________________________________________________________
SIGNATURE
PLEASE PRINT CLEARLY AND FIRMLY AND COMPLETE ALL APPLICABLE SECTIONS
DISTRIBUTION: WHITE–PERSONNEL COPY CANARY–PAYROLL COPY Form No. 6245 (Rev. 8/96) GREEN–INSURANCE COPY IF RETIRED, NOTIFY PERSONNEL AND INSURANCE