About this Form
Form number: 445-1
Audience: MCPS Staff
Last revised: August 2016
INSTRUCTIONS FOR EMPLOYEES/RETIREES: Please type or print. Use this form to change or correct your name, title, date of birth, address, and/or Social Security number (only after receipt of your new official Social Security card). Complete this form, sign, and return it to the Employee and Retiree Service Center (ERSC). You may fax the form to 301-279-3642/301-279-3651 or e-mail an electronically signed Adobe PDF file to ERSC@mcpsmd.org.
- You must complete ALL sections in the first box.
- You must go (in person) to your local Social Security Administration Office to complete the required form to change your Social Security records. Requested name changes will only be processed as they appear on your Social Security card.
- You must complete a new W-4 if you change marital status and/or number of exemptions for income tax withholding purposes. All W-4 changes are made online via Employee Self-Service (ESS). To access the online form, visit the ESS web page and click on My W-4 under the green My Pay banner. Log in using your MCPS username and password and follow the on-screen instructions. After submitting your changes, you will receive an e-mail confirmation.
- This form does not change the name and address record of the Maryland State Retirement Agency, Educational Services Federal Credit Union, retirement savings, etc.
- Retirees will need to contact Aetna and the Maryland State Retirement Agency for address changes.
Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat