Change Of Information Form - Miracosta College
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1MIRACOSTA COLLEGE
SCAN: FA MISC____________
CHANGE OF INFORMATION FORM
When completing this form, do NOT leave items 1 through 3 blank.
NOTE:
Check all that apply: □ Student □ Employee □ Instructor □ Other
STUDENT ID#
(OLD) Change Information FROM:
(NEW) Change Information TO:
1. Name
__________________________ ___________________ ____
___________________________ ___________________ ____
Last Name
First Name
MI
Last Name
First Name
MI
(Please Print)
(Please Print)
Must
□ This is NOT a name change.
E
D
C
: __________________________
complete
FFECTIVE
ATE OF
HANGE
this
married
section.
Reason for Change
divorced
other, explain______________________
This name MUST be your legal name as reported on your
social security card. A copy of your social security card in
your new name MUST accompany this form.
2. Social
Security
Old SSN: _____________-_____________-_________ __
New/Corrected SSN: _________ _-__________-___________
Number
□ This is NOT an SSN change.
If you are reporting a new/corrected Social Security
Must
Number, you MUST attach a copy of your social security
complete
card.
this
section.
3. Date of
_____________/______________/________________
________________/________________/_________________
Birth
Month
Date
Year
Month
Date
Year
Must
□ This is NOT a change.
If you are reporting a correction to your Date of Birth,
complete
this
you MUST attach a copy of your Birth Certificate.
section.
4. Address
Do not complete this section unless making a change.
New Mailing Address:
Old Mailing Address:
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
City
State
Zip Code
City
State
Zip Code
Old Residence Address:
New Residence Address:
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
City
State
Zip Code
City
State
Zip Code
(Students Only) Living Arrangements at new address:
□ live with parents
□ live with relative(s), other than spouse and/or
dependent children
□ other, specify:______________________________________
E
D
:_______________________
FFECTIVE
ATE OF THIS CHANGE
5. Phone
Do not complete this section unless making a change.
(_______) ____________ -
________________________
(_______) ____________ -
_________________________
6. Email
Do not complete this section unless making a change.
Signature:_______________________________________________________Date:________________________________________________
N
: If you currently work on campus, a marital status change requires a new W-4 be submitted to the Payroll Office.
OTE
If you are a benefited employee, insurance adjustments may be necessary.
Distribution: Human Resources/Payroll, MS 14, white, (attach SS card and/or Birth Cert)
Admissions Office, MS 10A, pink
Financial Aid Office, MS 3A, yellow, (attach SS card and/or Birth Cert)
Contributor Relations, MS 7, gold
Office Use Only: Posted by:__________________________Dept:______________________ Date:_______________________
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