Change Of Address/name Form - Erie County Department Of Personnel
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1ERIE COUNTY DEPARTMENT OF PERSONNEL ‐ CIVIL SERVICE EXAM DIVISION
CHANGE OF ADDRESS/NAME FORM
PLEASE COMPLETE THE FOLLOWING REQUIRED INFORMATION AND SUBMIT IN HARD COPY ONLY to:
Erie County Department of Personnel, 95 Franklin St., Buffalo, NY 14202.
PRINT NAME___________________________
EFFECTIVE DATE____/_____/_________
Phone Number _________________________
SOCIAL SECURITY #_____‐____‐______
CHANGE OF ADDRESS
New Address: _____________________________________________________________________
Street Address
City, State, Zip
Mailing Address (If different from above):
___________________________________________________________________________________
Street Address
City, State, Zip
THE FOLLOWING RESIDENCY INFORMATION IS IMPORTANT FOR RESULTING RESIDENTIAL CERTIFICATIONS OF A LIST:
(Incomplete information or inaccurate information may result in your name not appearing on a residential certification)
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**All changes are effective on the 15
of the Month following submission**
SCHOOL DISTRICT______________________________
VILLAGE______________________________
TOWN______________________________
NAME CHANGE
PREVIOUSLY HELD NAME:
Last ________________________________ First____________________________ Middle Initial_____
CURRENT/NEW NAME:
Last_________________________________First_____________________________Middle Initial_____
THIS AFFIRMATION MUST BE COMPLETED. I affirm that the statements made on this form are true under the penalties of
perjury. I understand that all statements made by me in connection with this form are subject to investigation and verification and
that a material misstatement, omission, or fraud may disqualify me from appointment or lead to revocation of my appointment.
SIGNATURE __________________________________________________ DATE ________/_____/__________
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