Rev. 10-19 A
STUDENT INFORMATION CHANGE FORM
COMPLETE ONLY THE INFORMATION TO BE CHANGED.
Photo identification and supporting documentation are required in order for this form to be processed.
DATA AS IT CURRENTLY EXISTS IN STUDENT RECORD (BANNER):
Student ID Number: _____________________________ Social Security Number: ______________________________
Last Name: _________________________________ First Name: _______________________ Middle: ______________
CHANGE OF NAME must submit a valid driver’s license/state id and one legal verification form of name
change (Acceptable documents include - marriage license, divorce decree, legal name change by court order, birth
certificate or Social Security card)
New Name:
Last: ____________________________________________First: _____________________________Middle: _______
CHANGE OF SOCIAL SECURITY NUMBER - must submit valid driver’s license/state id and Social Security
Card
Updated Social Security Number: ______________________________________________________________________
CHANGE OF DATE OF BIRTH must submit valid driver’s license/state id and birth certificate or U.S
passport
Updated Date of Birth: _______________________________________________________________________________
CHANGE OF ADDRESS/PHONE/EMAIL -
Street: ____________________________________________________________________________Apt #: __________
City: _______________________________________State: _____Zip Code: _____________ County: ________________
Phone: ___________________________________________________________________________________________
Home: _______________________Cell: ______________________Email: _____________________________________
Initial
I have verified that the changes I wish to make above match the SS# and birthdate listed on my FAFSA, if
applicable.
Student Signature: ______________________________________________________Date: _____________________
Updated Information will be corrected in 72 business hours. Please check your BANNER account after that time.
For staff use only:
RNANA__ for current aid year matches new DOB and SS#.
Copies attached: SS Card, DL/State ID, Birth Certificate/Passport, Legal Doc for Verification of Name Change.
Registrar Office staff notified IT of student’s new Active Directory Profile Information
ID Verified by:__________________
Processed by: _____________________ Date: ______________
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