Change in Marital Status or Name Change Cabinet members must report to the Bishop’s office and to the Conference Pension Benefits office of Holston Conference any change in marital status or name change for any and all clergy. Please use this form to report changes. Name of clergy person: _________________________________________________________ Address: _____________________________________________________________________ _______________________________________________________________________ Phone: (_____) ____________________
Fax: (_____) ____________________
E-Mail: ______________________________________________________________________ District: ______________________________________________________________________ Appointment: _________________________________________________________________ Status: _______________________________________________________________________ Participant Number: ____________________________________________________________ The following change in marital status has taken place for the person named above.
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New Married
Spouse’s Name: ____________________ Wedding Date:__________________ Please attach a copy of the marriage certificate.
Spouse’s Date of Birth: ____________________ Social Security #: _______________________
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Divorced
Name of Ex-Spouse: ________________ Date Divorce Finalized: ____________ Please attach a copy of the divorce decree.
Please briefly indicate how, as District Superintendent, you have followed our policy guidelines on marriage, separation and divorce: _______________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Legal Name Change (Minute Question #80) Former Full Name: _____________________________________________________________ New Full Name: _______________________________________________________________ Signed: ______________________________________________ Date: _________________________ (District Superintendent)
Revised January 20, 2021