Fillable Printable Generic Employee Status Change Form
Fillable Printable Generic Employee Status Change Form
Generic Employee Status Change Form
Revised 12/2012 Exhibit F-12 Form# FCP-06
Employee Status Change Form
GENERAL INFORMATION
Last: First: MI:
Social Security Number: Employee Number:
Department:
What do you want to change? Name (go to Section A) Address (go to Section B)
Section A NAME CHANGE
Note: Employee is required to provide legal proof for name change: Marriage Certificate / Divorce Decree / or other legal document.
Current Name:
Name - Last: First: MI:
Previous Name:
Name - Last: First: MI:
Section B ADDRESS CHANGE
Note: All fields are mandatory.
NEW INFORMATION
Home Address:
City: State: Zip: County:
Will you reside within Corporation Limits? Yes No If yes, list corporation:
School district in which you will reside: Does the school district have an income tax? Yes No
PREVIOUS INFORMATION
Home Address:
City: State: Zip: County:
Did you reside within Corporation Limits? Yes No If yes, list corporation:
School district in which you resided: Did the school district have an income tax? Yes No
Reminder: This form updates County records. Other change forms may be required to
update the records of insurance, OPERS/STRS and/or other independent parties.
Employee Signature: Date:
FOR AUDITOR’S OFFICE USE ONLY
Employee Number: __________________ Date recorded in system:_______________________
Date copied to H/R: __________________ Deputy Auditor Initials: _________________________
