Human Resources Department
303-273-3250

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’ll need to provide proof of change)
New Street Address: ___________________________________________
City, State, Zip ___________________________________________
Telephone Number-Home: _______________________ Cell: _____________________
(Please Check One)

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


Undergraduate

Graduate

Classified Staff - All Staff also must fill out a PERA Record Change Form

Faculty Retirement Accounts:
If PERA member, please complete a PERA Record Change Form.
If MDCP participant, log on to 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 Insurance




24Hour Flex





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

Employee Signature________________________ Date__________



Revised 06.16.2017