County Change Form
Return to your department head or
Tandra McClellan in County Clerk's Office
In an effort to update our records we are asking that each employee complete this form.
Please remember that marriage, divorce, births, etc. may affect your federal and state withholdings. Also, indicate if it is necessary for you to update/change your retirement and/or life insurance beneficiary.
Please PRINT all information
Name:_________________________________________________________________________________________
Address:_______________________________________________________________________________________
City:______________________________________ State:__________________ Zip:_________________________
Phone:____________________________________ Cell Phone:___________________________________________
Email Address:__________________________________________________________________________________
Direct Deposit Information: ONLY IF DIFFERENT
Bank Name______________________________________________________________
Routing________________________________________________________________________________________
Account________________________________________________________________________________________
Emergency contact:_______________________________________________________________________________
Emergency contact phone:__________________________________________________________________________
I will need to change my W-4 for the tax year. Yes_________ No________
I need to update/change my retirement beneficiary. Yes_________ No________
I need to update/change my life insurance beneficiary Yes_________No_________
Signature ______________________________________________ Date________________________________