CITY OF SAN CLEMENTE - DOC by sofiaie

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									                           CITY OF SAN CLEMENTE
                    EMPLOYEE PERSONAL DATA CHANGE FORM
Employees are required to notify the City’s Human Resources Department upon a change of
address, phone number, name, or email address used for payroll direct deposit. Please note that if
you have a name change, you will need to provide Human Resources with a copy of your new Social
Security card (or proof of your application for a new Social Security card) and marriage certificate if
applicable.

Please complete the appropriate blanks below and send the original form to Human
Resources. You will then receive the appropriate forms and instructions from Human
Resources to notify the various benefit providers of your change(s).


EFFECTIVE DATE: _____________                                EMPLOYEE NAME: _______________________________
                                                                                     (Please Print)

CHANGE MY:                     Address                       Phone #          Name 

                               Email Address for Direct Deposit 

NEW ADDRESS: ______________________________________________________________

                          ______________________________________________________________

NEW PHONE #:               ______________________________________________________________

NEW NAME:                  ______________________________________________________________

NEW EMAIL ADDRESS
FOR DIRECT DEPOSIT: ________________________________________________________


                                                   ________________________________________________
                                                                 Employee Signature


 For Human Resources Use Only:                                             For name changes:
                                                                            Copy of New Social Security Card __________
 For name, address & phone # changes:                                       Copy of marriage certificate __________
            FT/RPT - Memo & Providers Checklist __________                 New W4 Form ___________
            PT – Memo __________                                           Emergency Contact Form ___________
            Cal PERS Health __________                                     Beneficiary Forms: Great West, Standard, ICMA _______
            EDEN __________                                                Notify Great West/CalPERS Retirement __________
            Denver Reserve __________                                      Notify IT of the change _________
                                                                            Notify Payroll of the Change ________
 For email address changes:
                                                                            CalPERS, VSP & Delta Dental/Delta Care __________
            Update in “My Job” __________
                                                                            EDEN – Update Marital Status _________
                                                                            Update I-9 Employee Eligibility Verification (only if work
                                                                               authorization expires) __________

d:\docstoc\working\pdf\e2e0998a-a819-4eb4-8f7d-2190ecaff752.doc                                                     6/10/10

								
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