Data Change Notice (Form #30.W)

Employee Information

Employee Name (on MEBP's records) S.I.N. Employer Number Employer Name

Information on Record		New or Corrected Information
*(Only Changed Information Needs to be Entered)*
MAILING ADDRESS:

Employee

Information on Record		New or Corrected Information
*(Only Changed Information Needs to be Entered)*
SURNAME
GIVEN NAME
HOME PHONE #
CELL PHONE #
EMAIL
S.I.N.
BIRTH DATE
PROOF OF AGE (Y or N)
PLAN ENTRY DATE
If plan entry date changed, please give reason:
MARITAL STATUS

Spouse

Information on Record		New or Corrected Information
*(Only Changed Information Needs to be Entered)*
SURNAME
GIVEN NAME
BIRTH DATE
OTHER (specify)

Date of Change / Signature

Effective Date of Change
Date	Authorized Signing Officer

Employer Information

Employer Name Email

Additional Notes, Comments, or Explanation