ࡱ> ad` Mbjbj HT >[8lR\13 h2j2j2j2j2j2j2$472]% " "%%22(((%^8(J8h2(%h2((V(0@20Zwam%h0 T23013t0x58s&580580h !(@"t"[ 22'< 13%%%%58  :  CHAUTAUQUA COUNTY DEPARTMENT OF HUMAN RESOURCES GERACE OFFICE BUILDING (3 NORTH ERIE STREET MAYVILLE, NEW YORK 14757-1007 Phone: (716) 753-4237 ( Fax: (716) 753-4686 ( Internet: www.co.chautauqua.ny.us ( E-MAIL: cchrs@co.chautauqua.ny.us EMPLOYEE AND APPLICANT CHANGE OF NAME/HOME ADDRESS/PERSONAL EMAIL ADDRESS FORM NOTE: Your new contact information provided below will ONLY be used to update your employment and/or application records. EMPLOYEES OF CHAUTAUQUA COUNTY GOVERNMENT ONLY: If you are submitting a notice of name change please attach a copy of your new social security card, drivers license, and supporting documentation (marriage license, divorce decree, etc.). We cannot change your payroll/insurance record without that document. Please refer to the additional information on the reverse side of this form. Effective Date: ____________ Social Security Number: XXX-XX- _____ _____ _____ _____ Name New Name ____________________________________ ____________________________________ Last Name First Name MI Last Name First Name MI Former Home Address New Home Address and Phone No. ____________________________________ ____________________________________ Street Street ____________________________________ ____________________________________ City State Zip City State Zip ___________________ Phone Number New Personal Email Address: _________________________________________________ If you are changing your address please complete the legal residence information below for your new address: School DistrictCity or Village ofTown ofCounty ofState of Employment/examination candidates please note: This declaration is part of your application for examination or employment. Section 50 of Civil Service Law provides that any candidate who has intentionally made a false statement or has practiced, or attempted to practice, any deception or fraud in his application, in his examination, or in securing his eligibility or appointment may be disqualified. You may be required to produce documented evidence of your change of residence. Return this document to the office and address listed above. _____________________________________________________________ Signature Date Additional information for County Government Employees Only: If you changed your name and/or your home address, please complete the necessary tasks listed below that pertain to your situation.  Any questions, please feel free to contact the Chautauqua County Department of Human Resources at (716) 753-4237.     Employee ID#: __________ Payroll Cycle: ___________  ~ OVER ~ Revised 2/19/2019 NAME AND ADDRESS CHANGE CHECKLIST % NYS Retirement - New York State and Local Retirement System, forms are available at  HYPERLINK "http://www.osc.state.ny.us/retire/forms/index.php" www.osc.state.ny.us/retire/forms/index.php then click on forms. "Name Change Notice RS 5483" or if you've had a change in your beneficiaries "Designation of Beneficiary RS 5127" or "Designation of Beneficiary Trust RS 5127-T". % NYS Deferred Compensation - New York State Deferred Compensation forms are available at  HYPERLINK "http://www.nysdcp.com" www.nysdcp.com then click on forms. Under the section labeled "Changing Your Account" you will find forms such as "Address Change Form", "Beneficiary Change Form" and "Deferral Updates". You may also contact them directly at 1-800-422-8463. % E-Mail Account - If your name has changed, you may need to have your County e-mail account updated. This form is available on the Chautauqua County Intranet website under the Information Technology department. 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