Red ID:
Present Legal Last Name:
Address and / or Name Change Form
Please print clearly and use ink. Please complete entire form.
ADDRESS CHANGE
NAME CHANGE - Due to: Marriage Divorce Legal Name Change Other
Personal Information
Former Legal Last Name: Legal First Name: MI:
Legal First Name:
Email Address (used to receive SDSURF notifications):
Work Telephone Number: Home Telephone Number:
PM: Payroll Check Mailing Address (not a campus address)
Street Address Line 1:
Street Address Line 2:
Postal Code:State:City:
First Name:Last Name:
Emergency Contact Information
Relation:
Telephone Number (including area code):
If you have benefits with SDSURF: Your health, dental, and vision will be updated. If you have a TIAA account you will
need to update your information with them directly. Please go to www.tiaa.org and log in. Select the "My Profile" tab and
then click on "Beneficiaries". If you have AFLAC, Supplemental Life or Voluntary AD&D you will also need to update your
information with the applicable carrier.
Important:
If you are a current or former SDSU student, please be aware that this name change will also be made to your SDSU
academic transcript. If you would rather maintain your previous name on your transcript, please contact the Registrar's Office.
SIGNATURE: DATE:
For HR Use Only:
Social Security Card Viewed
E-class Orig. to Benefits Transaction Group
I-9
W-4 Copy to Payroll
HRIS/Computing Services Notified
Red ID Kiosk Updated
Last Updated 04/19/16 HRPYO1 Page 1 of 1
Event Date:
MI:
Required for Name Changes Only
