Personal Data Change Form

This form should be completed by current employees when updating information already on file (home address-W2, mailing address, campus address, phone number, legal name, preferred name, marital status, etc).

Check type of appointment:
Academic (Includes Resident Interns) Staff Student Academic Hourly

Current Name on File:

Social Security #: - -           Employee ID#:

(Please include SSN currently on file)

Check appropriate section below, and then provide updated information

SECTION 1: These changes must be verified at a university office. Legal documentation to support the change is required. Submit copy of social security card, marriage certificate, or official court document granting name change).

Legal Name:

Social Security #: - -

(Complete only if different from SSN in top section)

SECTION 2: Indicate updates, changes, or corrections to Marital Status or Date of Birth in this section. If making a change to Date of Birth, you will need to provide documentation that shows your correct Date of Birth. Please remember that if your change is to Marital Status, you may also need or want to make a corresponding change to your benefit coverage.

Please include Marital Status: S (Single) M (Married)

Date of Birth: / /

SECTION 3:

Preferred Name:

Home Address:

                                 Number, Street, Apt. #                City                                      State         Zip

Country Phone

Note: Home Address is used for mailed payroll checks, tax information including W2s and tax reporting to the IRS. All benefit enrollment information (for eligible employees) and faculty mailings are sent to this address. This is your legal residence.

Mailing Address:

                                   Number, Street, Apt. #                City                                      State         Zip

Country Phone

Note: Mailing Address is used for a temporary residence (e.g. student campus or faculty sabbatical residence, etc.) or P.O. address.

Campus Address:

                                    Dept/ORG Code       Building/Room       Street

City, State, Zip Code Campus Phone

Emergency Contact:

Name:

Address:

                   Number, Street, Apt. #                City                                      State         Zip

Phone                         Type  (home, cell, work)

Other Phone               Type (local, campus, cell, pager, non-IU work)

Signature: ____________________________________________________________________

Date: ______________________________