West Valley-Mission Community College District
NAME / ADDRESS CHANGE
Former Name:
New Name:
Date of Change: SSN:
Location:
New Address:
City: ST:
Zip:
Phone:
Classified Academic Full Time Part Time / Hourly
Signature Date
Accepted by:
Human Resources Representative
Date
Instructions for Name / Address Changes
1. Complete a change of beneficiary form for your respective retirement systems, if a member.
2. Update dependent coverage / address on health and welfare plans by completing the appropriate forms (see
Benefits Specialist to obtain correct forms).
3. Complete voluntary benefit program forms (TSA, 457, Flex Benefit, etc.)
4. Return all documents to Human Resources.
5. If Address Change Only, form may be completed by Human Resources Representative without employee signature.
Additional Instructions for Name Change Only!
1. Obtain new social security card reflecting new name. Bring to Human Resources for copying.
2. Complete new tax withholding forms.
Distribution of Documents by Human Resources
1. Original name change to be filed in employee’s personnel file and after entry into Datatel.
2. A copy of name change, withholding forms, and copy of social security card to be submitted to Payroll.
3. A copy of name change to be submitted to Benefits Specialist.
4. Official name change notification to respective STRS / PERS retirement system.
5. Copy to respective President’s Office.
Distribution: Original – Personnel File; 1
st
Copy – Payroll; 2
nd
Copy – Benefits Specialist; 3
rd
Copy – President’s Office
Change Processed: Datatel Personnel File HR Specialist - Initial / Date: _____________________________
HR/ras/01-05-06
