Return form to Payroll Office: Guggenheim Hall, 224 · 1500 Illinois St. Golden 80401


Change of Address/Name Form
(Please Print Legibly)
Name: _________________________________________________ CWID: ______________
New Name: _____________________________________________

(Requires new Social Security Card and I-9 Update)
(If name change affects benefits, you’l need to provide proof of change)
New Address: ___________________________________________

___________________________________________
Telephone Number-Home: _______________________ Cell: _____________________
(Please Check One)

Students - ALL Students must notify the Registrar’s Office of name changes


Undergraduate

Graduate

Classified Staff – You may change your address with PERA on the COLORADO PERA
website https://www.copera.org/colorado-pera or please request a PERA change of
address form.

Faculty Retirement Accounts:
If PERA member please change your address on the COLORADO PERA website
https://www.copera.org/colorado-pera or request a PERA change of address form.

If MDCP participate, log onto VALIC site and update your information.


Faculty: Please check appropriate box IF you would like the HR Department to change your
address with:




Anthem Medical/Dental/Vision Insurance




24Hour Flex





ALL EMPLOYEES ARE RESPONSIBLE FOR NOTIFYING YOUR
VOLUNTARY RETIREMENT PLAN PROVIDERS (403B/457)

Employee Signature________________________ Date__________



Revised 03.6.2018