Data Change Form Please check the box and fill out related information for the data change you need to make. You can leave all other fields blank (unless noted as required). "*" indicates required fields Client Company* Date* MM slash DD slash YYYY Employee Name* First Last Payroll ChangesEffective pay period beginning date MM slash DD slash YYYY New rate of payPay Frequency Per Hour Per Week Per Bi-Weekly Per Semi-Monthly Per Month Workers Comp Code Workers Comp Code: Workers Comp Code Title Title: Title Other ChangesAddress Address: AddressIf this change will affect your state withholding status, please contact TEL Staffing & HR Payroll Department at 850.476.9008. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number Telephone Number: Telephone NumberName Name: NameMust provide legal documentation First Last Stop Direct Deposit Stop Direct Deposit: Financial InstitutionFinancial Institution Account Info Account # Routing # Other Other: OtherPlease explain in detail.Supervisor Signature* By typing your name on any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.Date* MM slash DD slash YYYY Δ