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2. Please provide the name of the retiree while they were employed with the City of WInston-Salem.
4. First Name*
5. Middle Name
6. Last Name*
7. Suffix (if applicable)
9. Last Four Digits of SSN*
10. City Employee Number (if available)
12. Introduction

    Please select the type of information you wish to update with the City of Winston-Salem. 

14. PLEASE PROVIDE YOUR CURRENT CONTACT INFORMATION
15. IF YOU ARE CHANGING YOUR INFORMATION, PLEASE ADD BELOW
17. Current Street Address*
18. New Address (if applicable)
20. Current City, State, ZIP*
21. New City, State, ZIP (if applicable)
23. Current Telephone Number
24. New Telephone Number (if applicable)
26. Current Email Address
27. New Email Address (if applicable)
29. File Upload

    Any request for a change in name or social security number must be submitted with official documentation verifying the change being requested. In order to change your name, you MUST have a marriage certificate/divorce decree AND a government issued document showing your new legal name. For example, a driver's license or a social security card. If those do not apply, then you must provide an Order of Name Change certificate issued by a court. 

31. CERTIFICATION*

    By clicking the box below, I certify that I am attempting to change my personal contact information with the City of Winston-Salem. I understand that, by submitting this form, the City of Winston-Salem is authorized to change my contact information in its databases and to correspond with me using the information I have provided.

    Users who use this form without permission of the retiree whose information will be prosecuted. 

    1. I agree.
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field