State statute
Santa Clara — HR-054*
California foreclosure, tax-defaulted, court-ordered and probate-sale law and official procedures — verbatim and citable.
- Edition
- 2026-09-26
- Last updated
- 2026-09-27
- Jurisdiction
- Santa Clara County
Santa Clara — HR-054¶
Page 1¶
Superior Court of California County of Santa Clara Human Resources 191 North First Street San José, CA 95113 Telephone: (408) 882-2703 Fax: (408) 882-2796 Email: RetireeBenefits@scscourt.org
RETIREE/SURVIVOR OF RETIREE CONTACT INFORMATION CHANGE FORM
Retiree Survivor of Retiree
SECTION 1: Participant Information Full Name (First Name, Middle Initial and Last Name): _____________________________________________
If Survivor of Retiree, please provide name of Retiree: _____________________________________________
Retiree ID or last 4 of SSN: ________________________________________________________________________________
SECTION 2: New Contact Information – Home Address
In care of (if applicable): ________________________________________________________________________
Address: ________________________________________________________________________
PO Box: _______________ City: ________________ State: _______ Zip Code: ____________
Province/Territory: ________________________________ Country: ________________________________
Phone Number: ______________________________________________________________________________
Email Address: ______________________________________________________________________________
SECTION 3: New Contact Information – Mailing Address
In care of (if applicable): ________________________________________________________________________
Address: ________________________________________________________________________
PO Box: _______________ City: ________________ State: _______ Zip Code: ____________
Province/Territory: ________________________________ Country: ________________________________
Phone Number: ______________________________________________________________________________
Email Address: ______________________________________________________________________________
SECTION 4: I authorize, _______________________________, to □ send/receive email, □ speak, and/or (First Name Last Name)
□ send/receive official notices to/from the Court regarding my Retiree Health benefits (check all that apply).
SECTION 5: Required Signature
SIGN
Signature: Date:
HR-054 Rev. 3/5/2025 FOR HR USE ONLY: Entered into database on: ______________ Notified provider on: ___________________ Notified JCC on: _________________