"Change of Address, Name and Marital Status Form" - Rhode Island

Change of Address, Name and Marital Status Form is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

Form Details:

  • Released on July 30, 2020;
  • The latest edition currently provided by the Rhode Island Department of Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Administration.

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Download "Change of Address, Name and Marital Status Form" - Rhode Island

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Revised 7-30-20
DEPARTMENT OF ADMINISTRATION
Division of Human Resources
Change of Address, Name, or Marital Form
rd
One Capitol Hill – 3
Floor
Providence, RI 02908-5890
Phone: (401) 222-2160
Fax: (401) 222-6375
General Employee Information:
Name of Employee:
Home Phone #:
(If changing name, use old name here and complete the Name Change section below)
Department & Division/Section:
Change of Address:
Old Address:
Number
Street
City
State
Zip
New Address:
Number
Street
City
State
Zip
***If new mailing address is a post office box, please indicate residence address below:
Residence Address:
Number
Street
City
State
Zip
Change of Name:
Old Name: ____________________________________ New Name: __________________________________
(as it appears on old social security card)
(as it appears on new social security card)
Important: A copy of a legal document which shows your new name must accompany this form!
Examples include your driver’s license, social security card or voter registration card.
Page 1 of 2
Revised 7-30-20
DEPARTMENT OF ADMINISTRATION
Division of Human Resources
Change of Address, Name, or Marital Form
rd
One Capitol Hill – 3
Floor
Providence, RI 02908-5890
Phone: (401) 222-2160
Fax: (401) 222-6375
General Employee Information:
Name of Employee:
Home Phone #:
(If changing name, use old name here and complete the Name Change section below)
Department & Division/Section:
Change of Address:
Old Address:
Number
Street
City
State
Zip
New Address:
Number
Street
City
State
Zip
***If new mailing address is a post office box, please indicate residence address below:
Residence Address:
Number
Street
City
State
Zip
Change of Name:
Old Name: ____________________________________ New Name: __________________________________
(as it appears on old social security card)
(as it appears on new social security card)
Important: A copy of a legal document which shows your new name must accompany this form!
Examples include your driver’s license, social security card or voter registration card.
Page 1 of 2
Change in marital status:
From : ____________________________
To: ______________________________
Important: A copy of a marriage certification, divorce decree or other legal document must accompany this form!
Employee Signature:
Signature of Employee : _____________________________________________________
Date : ____________________
Important Information:
This form will update your name/address in the State's personnel system as well as with most of the State's
benefits vendors. Note that the following State benefit vendors require that you update any address and/or
name changes directly with them on your own:
Aflac (Short Term Disability): 401-475-9936, ext. 130
Colonial Life (Short Term Disability): http://www.visityouville.com/en/StateOfRI; or 866-349-8011
College Bound Saver (529 Plan): https://www.collegeboundsaver.com/; or 877-517-4829
This Form must be submitted to your local human resources representative for processing.
Please either print and sign or apply a certified digital signature.
For an up-to-date listing of human resources representatives for each assigned
Executive Branch agency, click here.
For all other non-Executive Branch organizations, please submit this form
to your local administrative representative.
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