Notice Regarding Change Of Address Form

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NOTICE REGARDING CHANGE OF ADDRESS
Date: _________________
To: Federal Human Resources Branch (AD-442)
Employee Name: _____________________________________________________
Social Security Number: _______________________________________________
Organization: ________________________________________________________
Please update my official records to include the following change of address:
Street Address/Post Office Box: _________________________________________
City: __________________________ State: _____ Zip Code: _______________
County: _______________________
I understand that this request will be used to change my home address for the purpose of receiving
correspondence such as: my Earnings and Leave Statement, Thrift Savings Plan Participant Statement, and W-2
Tax Statement.
____________________________________
Signature
cc:
Oak Ridge Financial Service Center (FM-71)
Assistant Manager for Security and Emergency Management (OS-20)
Note: For savings bond address changes, complete a savings bond card and forward to the Oak Ridge
Financial Service Center. The address that your savings bonds are mailed to will not be changed solely
on the basis of submittal of this form.
PRIVACY ACT NOTICE
Your Social Security Number (SSN) is requested under the authority of Executive Order 9397 in order to ensure that the information is maintained
only with other records pertinent to you and not with information of other individuals who may have the same name. The information you provide
on this form will be primarily used to update the records maintained in a system of records that contain your home address and that are used by the
human resources and payroll offices. Furnishing your SSN is voluntary; but, if the SSN is not provided, there may be a delay in your receipt of
information from the Department of Energy, such as your bi-weekly Earnings, Leave, and Benefits Statement; Travel Voucher information;
information sent via mail from the Human Resource Office; or your W-2. In addition, the information provided on the form may be provided to
training facilities; to organizations deciding claims for retirement, insurance, unemployment or health benefits; to officials in litigation or
administrative proceedings where the Government is a party; to law enforcement agencies concerning violations of law or regulation; to labor
organizations recognized by law in connection with representing employees; to Federal agencies or other sources requesting information for Federal
agencies in connection with hiring or retaining security clearances; to the Merit Systems Protection Board, the Office of Special Counsel, the Equal
Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives, the Federal Acquisition Institute and
congressional offices in connection with their official functions
.

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