Employee Change Notice Form

Date *

Year

Month

Day

Input date in the following format: yyyy/mm/dd

First name, Middle, Last Name *

Email address *

Effective Date of Change *

Year

Month

Day

Please enter the date you want this to be effective.

New Address

For address updates, please enter street, city, state, and zip code.

New Phone Type

Home

Cell

Please indicate the new number as a home or cell phone number.

New Phone Number

Please enter the new number(s) including the area code in the following format: (0123456789)

New Phone Type 2

Home

Cell

Please indicate the new number as a home or cell phone number.

New Phone Number 2

Please enter the new number(s) including the area code in the following format: (0123456789)

Marital Status

Please indicate the status change and present Human Resources with legal documentation, i.e. marriage license, divorce decree, social security card to support the requested change. A marital status change may warrant an update of your W4 & beneficiary information. Contact Human Resources to complete these updates, if applicable.

Name Change

Please enter name changes in the following format: First name, Middle Initial, Last Name. NOTE: Name changes will not be processed by payroll until a new Social Security Card is presented, at which time a new W4 will be required.

Dependent Children

Please indicate the situation of your dependent children

Dependent Children Name(s)

i.e. First Name, Middle Initial, Last Name

Dependent Children Birthdate(s)

Year

Month

Day

Electronic Signature *

By submitting this electronic form you authorize Human Resources to make the necessary changes to your information.

LU ID# *

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