Superior Court of California
County of Santa Clara
Human Resources
191 North First Street
San José, CA 95113
Telephone: (408) 882-2703
Fax: (408) 882-2796
Email: RetireeBenefits@scscourt.org
RETIREE/SURVIVOR OF RETIREE CONTACT INFORMATION CHANGE FORM
Retiree Survivor of Retiree
SECTION 1: Participant Information
Full Name (First Name, Middle Initial and Last Name):
If Survivor of Retiree, please provide name of Retiree:
Retiree ID or Social Security Number:
SECTION 2: New Contact Information – Home Address
In care of (if applicable):
SECTION 3: New Contact Information – Mailing Address
In care of (if applicable):
SECTION 4: I authorize, to send/receive email, speak,
(First Name, Last Name)
and/or send/receive official notices to/from the Court regarding my Retiree Health benefits (check
all that apply).
SECTION 5: Required Signature
Signature: Date:
HR-054 NEW 3/16/16
FOR HR USE ONLY: Entered into database on: ______________ Notified provider on: ___________________ Notified DOR on: _________________
click to sign
signature
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