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ADDRESS CHANGE Nye County Human Resources EMPLOYEE NAME / ADDRESS CHANGE FORM Name SSN Phone Number NAME CHANGE *Name will not be changed in the payroll system unless a new Social Security Card reflecting the new name is attached. New Address: Please change my address with the following: o Nye County Payroll System, I understand that for Social Security reporting purposes, my name must appear in the Payroll System the same as it appears on my Social Security Card. I further understand that my W-2 form will be mailed to this address. Sierra Health & Life Insurance o Ameritas ~ Dental/ Vision Signature Date Revised 7.19.16 rg (775) 482-7242 - Fax: 482-7245 ·101 Radar Road - PO Box 3400, Tonopah, NV 89049 (775) 751-6301 - Fax: 751-6309 · 2100 E Walt Williams Drive, #110 Pahrump, NV 89048 Old Name: New Name: o