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County Change Form

 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________________________________