Download Report

SCOTTSDALE UNIFIED SCHOOL DISTRICT
ADDRESS / NAME CHANGE FORM
DIRECTIONS: Classified and Certified employees must use this form when requesting an address / name
change. Certified employees must include an updated teacher certificate, social security card and driver’s
license/state ID for verification. Classified employees must include an updated social security card and driver’s
license/state ID for verification. Please read carefully the information printed below; sign and submit to the
Benefits Department. PLEASE PRINT CLEARLY.
Employee’s Name on File_____________________________________ Last 4 digits of SSN ______________
School/Dept _________________________________
Circle One:
CERTIFIED EMPLOYEE
Work Phone or email ___________________________
or
CLASSIFIED EMPLOYEE
The following information is being submitted to the Scottsdale Unified School District Benefits Department to
update or change the data in the personnel and benefit systems:
ADDRESS CHANGE
NEW ADDRESS
CITY, STATE, ZIP
EFFECTIVE DATE OF ADDRESS CHANGE
NEW TELEPHONE NUMBER
NAME CHANGE
CURRENT NAME ON FILE
CHANGE NAME TO
EFFECTIVE DATE OF NAME CHANGE
MARITAL STATUS (check one box)
SINGLE
Employee’s Signature _________________________________________________
MARRIED
Date __________________
To Be Completed by the Benefits Department
Received By __________________________
Teaching Certificate Received ________ (date)
Social Security Card Received________ (date)
Driver’s License Received ___________ (date)
Copy IT Department ________ Copy Payroll Department ________ Copy HR Department ________
Revised 4/15/2015 smc
ARIZONA STATE RETIREMENT SYSTEM (ASRS)
CHANGE OF NAME FORM
COMPLETE AND SEND
TO:ASRS
PO Box 33910
Phoenix, AZ 85067-3910
Phoenix (602) 240-2000
Tucson (520) 239-3100
Toll-Free (800) 621-3778
Fax
(602) 240-2096
www.azasrs.gov
Disclosure of your Social Security number is mandated by Section 6109 of the Internal Revenue Code. The ASRS will use Social
Security numbers only to obtain information about an individual’s ASRS account and to inform the Internal Revenue Service of
distributions and withholdings with respect to the individual’s account.
SECTION 1 – Member Information (Name currently on file with the ASRS.)
Social Security Number
Member Name (Last)
(First)
(Middle Initial)
Mailing Address
City
State
Date of Birth (MM/DD/YYYY)
ZIP
Daytime Telephone Number
Email Address
SECTION 2 – Name Change (Enter your new legal name.)
New Name (Last)
(First)
(Middle Initial)
A copy of the legal document establishing the name change must be included with this form. Check which one is enclosed.
Divorce Decree
Marriage License
Passport
Social Security Card
Driver License
Court Order (type?)
SECTION 3 – Signature
Member Signature
Date
Any person who knowingly makes any false statement, or who falsifies or permits to be falsified any record of the retirement plan with
an intent to defraud the plan is guilty of a Class 6 felony per Arizona Revised Statutes § 38-793.
DO NOT EMAIL THIS FORM - PRINT AND SIGN
PRINT
Change of Name
Page 1 of 1
Revised: 12/01/11
APPLICATION FOR
NAME CHANGE OR DUPLICATE COPY OF CERTIFICATE
ARIZONA DEPARTMENT OF EDUCATION – CERTIFICATION UNIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: (602) 542-4367
GENERAL INSTRUCTIONS AND INFORMATION:
Please submit the following:
Step 1: Complete this application, sign and date.
Step 2: Mail the following to: ADE - Certification Unit, P.O. Box 6490, Phoenix, AZ 85005-6490:
Checklist:
 Completed application, signed and dated.
 $20 personal check, money order or cashier’s check made payable to the
“Arizona Department of Education”. Fees are not refundable. Cash will not be accepted.
 If applying for a name change, proof of name change must be included, see below. Photocopies accepted.
Step 3: The Certification Unit will review your application for completeness, correct fee and proof of name change (if
applicable). Once verified, a new printed certificate will be mailed to the address below.
SECTION 1: PERSONAL INFORMATION (TYPE OR PRINT IN BLUE OR BLACK INK)
Social Security Number:
________-_______-__________
Date of Birth:
_____/_____/________
Gender: M/F
(For identification purposes only)
Full Legal Name:
________________________________________________________________________________________________
Last
Mailing Address:
First
________________________________________________________________________________________________
Street Number or P.O. Box
Telephone:
Ethnicity:
Middle
City
(______) ______-________
State
Email Address:
____ Asian or Pacific Islander
____ White (Not-Hispanic)
Zip
_________________________________________
____Black or African-American (Not-Hispanic)
____American Indian or Alaskan Native
____Hispanic or Latino
____Other
(Gender and Ethnicity are requested for federal reporting purposes only)
SECTION 2: SERVICE(S) REQUESTED
PLEASE PLACE AN “X” ON THE LINE NEXT TO THE REQUESTED SERVICE, SIGN AND DATE
____
A duplicate copy of my certificate.
____
A name change of my educator file due to my name being legally changed.
 Submit proof of name change. Acceptable forms of proof include: Marriage License, Driver’s License, Court
Order or Divorce Decree. Photocopies accepted.
FORMER NAME: ________________________________________________________________________________
Last
First
Middle
NEW NAME: ________________________________________________________________________________
Last
First
Middle
_______________________________________________________________
Applicant’s Signature
_________________
Date
** REQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE ARIZONA REVISED STATUTES AND ADMINISTRATIVE CODE. **
Version 3.1 (Revised 2-5-2013)
WWW.AZED.GOV/EDUCATOR-CERTIFICATION/
Page 1 of 1