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Change of Name and or Marital Status

Forms to Complete

Employees need to complete federal withholding allowance form W-4 and state form M-4 to change their name and/or tax filing status.  These forms can be found on the Human Resources Forms page. 

Send the original, completed W-4 form to the PPS payroll department at 72 Pilgrim Road.

Social Security Administration

Employees with a name change need to notify the Social Security Administration using this link:
https://faq.ssa.gov/en-us/Topic/article/KA-01981

Massachusetts Department of Elementary and Secondary Education

You will need to update your ELAR profile and license. Complete and submit the Request for a Name
Change Form along with proof of name change (copy of marriage certificate, social security card,
driver's license, etc.), and submit these documents to the Office of Educator Licensure via the methods
stipulated on the form. https://www.doe.mass.edu/licensure/faq-glossary/send-required-docs.html

Insurance Coverage and Other Benefits

Please contact the Town of Pembroke, Treasurer’s Office at 781-293-3893 or email Jennifer Grasso
at jgrasso@townofpembroke.org, within 30 days of the qualifying event to request a change in
coverage type or to a subscriber’s name. Documentation such as marriage certificate, Judgment of
Divorce or sections of the divorce decree pertaining to the name change and/or coverage of former
spouse and dependents, if applicable, are required by our health group, Mayflower Municipal.

If you are a member of our health and/or dental insurance plans, you have the following options:

  1. Remain as an individual member
  2. Change from individual to family coverage within 30 days of the qualifying event
  3. Cancel your membership if electing spouse’s coverage

Updated enrollment forms must be completed for name change requests and/or changes to your
plan’s coverage type along with updating your beneficiary selection (optional) if currently enrolled
in our life insurance policies. These forms can be found on the Town’s website or by using this link
https://www.pembroke-ma.gov/human-resources/pages/benefit-information-current-employees.

Life Insurance

If you carry life insurance through school, and you wish to change the beneficiary on your policy. Please contact the Pembroke Town Treasurer Department, 100 Center Street, 781-709-1421, within 30 days of the event for all benefit inquiries.