Address Change Notification Form

ADDRESS CHANGE NOTIFICATION FORM

Recipient Name:    Date of Notice:

Account / Reference Number:    Primary Contact Phone:

RECITALS

WHEREAS, the Notifying Party is a customer, vendor, or other authorized party associated with the Recipient and has responsibilities or entitlements under accounts or services maintained by the Recipient; and

WHEREAS, the Notifying Party desires to update the Recipient’s records to reflect a change in the Notifying Party’s mailing, billing, and legal process addresses to ensure proper delivery of notices, invoices, and other communications; and

WHEREAS, the Recipient requires written notification and reasonable time to effect administrative changes and to communicate any additional requirements to the Notifying Party.

UPDATED ADDRESS DETAILS

Effective Date for New Address:    Mail Forwarding Start Date (if requested):

SCOPE OF NOTIFICATION

Describe accounts, services, or document types to which this address change applies (e.g., billing, legal notices, deliveries, tax documents). Provide account identifiers where applicable.

TYPES OF CHANGE (CHECK ALL THAT APPLY)

Mailing Address
Billing / Invoicing Address
Legal / Service of Process Address
Delivery / Shipping Address
Tax / Regulatory Correspondence

PAYMENT AND OUTSTANDING BALANCE (IF APPLICABLE)

The parties acknowledge that a change of address does not alter any outstanding payment obligations. Specify any known outstanding balance to be associated with this account.

Late fee or interest on overdue amounts:

TERM, TERMINATION, AND NOTICE

This notification becomes effective on the Effective Date provided herein, subject to the Recipient’s administrative processing time. The Recipient may require additional documentation to effect changes for certain account types. The Notifying Party may revoke or amend this notification by providing written notice according to the Recipient’s procedures.

Notice Period for revocation or further changes (days):

CONFIDENTIALITY

The Recipient will handle the Notifying Party’s personal and account information in accordance with its privacy and security policies and applicable law. The Recipient may disclose the Notifying Party’s updated address to third parties where required to deliver notices, fulfill services, or comply with legal obligations. The Recipient will use reasonable administrative safeguards to protect personal information but is not liable for unauthorized disclosures resulting from third-party processing or transmission.

AUTHORIZATION, REPRESENTATIONS, AND INDEMNITY

The Notifying Party represents and warrants that the information provided is true, accurate, and complete, and that the person signing below is authorized to request this change on behalf of the Notifying Party. The Notifying Party agrees to indemnify and hold harmless the Recipient from claims, losses, or liabilities arising from reliance on inaccurate or incomplete information provided in this notification, except to the extent directly resulting from the Recipient’s gross negligence or willful misconduct.

GOVERNING LAW; ENTIRE AGREEMENT

This notification and any administrative procedures required by the Recipient are governed by the laws of the state or jurisdiction in which the Recipient maintains its principal place of business, without regard to conflict-of-law principles. This document constitutes the entire written notification of address change between the parties with respect to the subject matter hereof and supersedes any prior written or oral communications concerning the same.

ADDITIONAL INSTRUCTIONS / NOTES

AUTHORIZING SIGNATURE

By signing below, the undersigned certifies under penalty of perjury that they are authorized to effect the address change for the account(s) listed, that the information provided herein is true and correct, and that they understand the Recipient’s processing time and possible requirements for additional verification.

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