Fillable UC HUMAN RESOURCES ADDRESS CHANGE NOTICE

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UC HUMAN RESOURCES ADDRESS CHANGE NOTICE

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PERSONAL INFORMATION
NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER FORMER CAMPUS/LAB
EMPLOYEE ID NUMBER DATE OF BIRTH (MO/DAY/YEAR) CURRENT DAYTIME PHONE NEW DAYTIME PHONE (If known)
CHECK ONE:
NEW HOME ADDRESS (Number, Street) EFFECTIVE DATE
(City, State, ZIP, Country)
PREVIOUS HOME ADDRESS (Number, Street, City, State, ZIP, Country)
I am a UCRP retiree/survivor.
I am receiving UCRP disability
income.
I am a CalPERS retiree/survivor with health coverage or CalPERS
VERIP through the University.
Other:_____________________________________
( )
FORMS REQUEST
Please send me these forms:
Retiree Continuation, Enrollment or Change—Medical, Dental and/or Legal Plan (UBEN 100)
Tax Withholding Election for UCRP Income (UBEN 106)
Designation of Beneciary—Retirees, Former Employees and Others (UBEN 117)
Direct Deposit for Monthly Benets (UCRS 160)
SIGNATURE OF RETIREE OR FORMER EMPLOYEE (required)
(All other signatures require proper power of attorney documentation on le with UC Human Resources.)
SIGNATURE DATE
PLEASE PRINT
( )
Complete form in ink and send to:
UC Human Resources
Attn: Retirement Administration
Service Center
P.O. Box 24570
Oakland, CA 94623-1570
SEE REVERSE FOR PRIVACY NOTIFICATIONS
UC HUMAN RESOURCES ADDRESS CHANGE NOTICE
FOR RETIREES AND FORMER EMPLOYEES
UBEN 131 (R4/17) University of California Human Resources
THIS FORM IS FOR RETIREES AND FORMER EMPLOYEES ONLY.
Use this form to report an address change. Fill in this form completely and send to UC Human Resources, Attn: Retirement
Administration Service Center, P.O. Box 24570, Oakland CA 94623-1570. If you recently sent us an address change and
received this form in return, we need additional information to fully update our records.
Do not use this form if you want to report a name change only. Instead, send a letter to UC Human Resources,
Attn: Retirement Administration Service Center, P.O. Box 24570, Oakland CA 94623-1570 and include your signature, Social
Security number and a copy of your marriage license or other legal documents showing the name change. Indicate exactly
how you wish your name to appear in our records. We try to incorporate at least one given name, an initial, and surname.
Examples: Mary Jones-Smith, Pearl F.A. Wu, John T. Doe, Jr.
If you are an active employee, you can change your address online. On the UCnet website (ucnet.universityofcalifornia.edu),
select “AYS Online,” then select “My Contact Information.” You can also report address changes to your departmental personnel
representative or local Payroll Office.
To request other forms listed in the Forms Request section, check the appropriate box(es) below to change insurance
plans because you’ve moved outside the service plan area, or add/delete eligible family members from your insurance plans
(UBEN 100); update your tax withholding (UBEN 106), change beneciaries (UBEN 117), or change electronic deposit
arrangements (UCRS 160).
PRIVACY NOTIFICATIONS
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following
information to individuals who are asked to supply information about themselves.
The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity,
and/or for benets administration, and/or federal and state income tax reporting. University policy and state and federal statutes
authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even
prevent completion of the action for which the form is being lled out. Information furnished on this form may be transmitted to
the federal and state governments when required by law.
Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining
agreements. Information on applicable policies and agreements can be obtained from campus or Office of the President Staff
and Academic Personnel Offices.
The official responsible for maintaining the information contained on this form is the Vice President—University of California
Human Resources, 1111 Franklin Street, Oakland, CA 94607-5200.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notied that disclosure of your Social Security number is mandatory.
The University’s record keeping system was established prior to January 1, 1975 under the authority of The Regents of the
University of California under Article IX, Section 9 of the California Constitution. The principal uses of your Social Security
number shall be for state tax and federal income tax (under Internal Revenue Code sections 6011.6051 and 6059) reporting,
and/or for benets administration, and/or to verify your identity.
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UC HUMAN RESOURCES ADDRESS CHANGE NOTICE

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Completed 12 November 2020

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