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Institutional Finance & Administration
KUMC  :  Institutional Finance & Administration  :  Payroll  :  Affiliate Name/Address Change
Payroll

The University of Kansas Medical Center
Affiliate Name/Address Change Form

Red fields are required (form will not be sent if information is not entered in these fields)

CURRENT INFORMATION

Current Name:(last, first, mi)

Current Preferred Name:

 

NEW NAME
New Name: (last, first, mi)

NOTE: You must provide an updated social security card for verification of name change either in person (4125 Rainbow Blvd., Room 1004) or FAX to (913) 588-5228.

New Preferred Name:

 

NEW RESIDENCE ADDRESS

Address: Apt/Box:

City:   State:  Zip Code:

County In Which You Reside:

 

NEW BUSINESS/WORK ADDRESS

Address:
                 

City:   State:   Zip Code:

COUNTY where business/work is located:
If you have any questions about completing this form call X 8-5100.

 

Comments:

 

THIS FORM WAS COMPLETED BY

Name:

Phone:

KUMC E-mail: