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Employee Change Of Personal Information

Effective Date

Employee Name (previous name if change)

For Changes Only:

Name

Address

Phone Number

Marital Status:

[ ] Single [ ] Married [ ] Divorced

Note: An employee is not obligated to report marital Beaus to his or her employer, but the employee may wish to report marital status so the employer can adjust the tax withholding amount.

Signature _______________________ Date ___________.

* Please fill out and return to the Personnel Department.