BYRON-BERGEN CENTRAL SCHOOL DISTRICT

EMPLOYEE CHANGE INFORMATION

NAME: ____________________________________	DATE: ____________________

Reason for Change:

Effective Date of Change:

________________________________ (e.g., Marriage, Divorce, New Address)

________________________________

PLEASE CHANGE:	Address	___________________________________________

___________________________________________

Primary Phone #

Secondary Phone #

(_____) _________________________ Area Code

(_____) _________________________ Area Code

Other	___________________________________________

IMPORTANT NOTES:

If you get married and are changing your name, the Business Office will need to see your original marriage certificate and original Social Security card (with your new name on it), along with this form completed.

If you have gotten divorced, the Business Office needs to see your divorce paperwork (for health insurance purposes).

Retirement System Changes: You will need to complete the appropriate forms for ERS (Employees’ Retirement System) or TRS (Teachers’ Retirement System) if you have any changes (e.g, name, address, beneficiary, etc.). The forms are located:

NYSERS: https://www.osc.state.ny.us/retire/forms/#member NYSTRS: https://www.nystrs.org/forms

Healthcare Enrollment/Change: The Business Office will give the form to you to complete.

PLEASE RETURN THIS FORM TO THE BUSINESS OFFICE.

FOR OFFICE USE ONLY

Payroll, vendor listing Healthcare, by office Healthcare, form given Retirement System, form given

Superintendent’s Secretary (Instant Connect) Principal’s Office
Email Counseling (SchoolTool) Email Technology

pgunio/Forms/Employee Change Info Form – Rev. 6-26-19