Social Security Number Change Form printable pdf download

Social Security Number Change Form

NU ID:__________________________

Date:_________________________

Name: _______________________________________________________________________

Last

First

Middle

Other

Address: ______________________________________________________________________

Street

City

State

Zip

Phone (__________)__________________________________

Date of Birth________________________________________

Social Security Number: _______-______-________

Former Social Security Number: _______-______-________

Must provide a copy of Social Security Card for SSN change:

I hereby authorize my Social Security Number to be changed as indicated on all current and

subsequent entries to my permanent record at the University of Nebraska at Kearney. I also

authorize the Registrar’s Office to provide a copy of my social security card to the Human

Resources Office at the University of Nebraska at Kearney to update my employment record, if

applicable.

Signature: ________________________________________________

Please print off and mail (please do not send electronically or by FAX) with a photocopy of

your Social Security card to:

Registrar’s Office - Founders Hall

2504 9

Ave

Kearney, NE 68849

7/2/14

Social Security Number Change Form