Personal Information Change Form printable pdf download

Personal Information Change Form

EPARTMENT OF

& M

UDGET

ANAGEMENT

T. ELOISE FOSTER

MARTIN O’MALLEY

Governor

Secretary

DAVID C. ROMANS

ANTHONY BROWN

Lieutenant Governor

Deputy Secretary

PERSONAL INFORMATION CHANGE FORM

Please complete this form to update the information we have on file for you at the Employee Benefits

Personal Information Change Form

Division. This

can also be found on the Department of Budget and

Management website at then click on Forms. The completed form

can be faxed to 410-333-7104 or mailed to:

Department of Budget & Management

Employee Benefits Division

301 W. Preston Street

Room 510

Baltimore, Maryland 21201

Status (please check one): Active Employee: ____ Satellite Employee: ____

Direct Pay: ____

Retiree: ____

EMPLOYEE/RETIREE SOCIAL SECURITY NUMBER: _____________________________________

NAME: ______________________________________________________________________

If Name Change:

NEW NAME: ________________________________________________________

(Legal proof of name change MUST be attached to this form)

STREET ADDRESS: ___________________________________________________________

CITY: ________________________________STATE:_____________ZIP:________________

DATE OF BIRTH: __________________

WORK PHONE: ___________________ HOME PHONE: ______________________

CELL PHONE: ____________________

PERSONAL EMAIL ADDRESS: ___________________________________________

WORK EMAIL ADDRESS: ______________________________________________

_________________________________________

_______________________________________

Employee/Retiree Signature

Date

Personal Information Change Form

Note: This

is only for use within the Employee Benefits

Division. If your personal information is not correct with the Central Payroll Bureau or the

Maryland State Retirement Agency, those agencies need to be contacted independently as a

separate form is required.

•

301 W. Preston Street, Room 510

Baltimore, MD 21201

•

Tel: (410) 767-4775

Fax: (410) 333-7104

Toll Free: 1 (800) 307-8283

TTY Users: call via Maryland Relay

Personal Information Change Form

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