Change of Address Name Form

CHANGE OF ADDRESS / NAME FORM

WHEREAS, Client Name: (hereinafter "Client") maintains records with Service Entity: ; and

WHEREAS, Client desires to update official contact information and, where applicable, legal name, and Service Entity is willing to process such updates in accordance with the terms and conditions set forth in this form.

WHEREAS, the parties intend for this document to serve both as an authorization to change records and as a binding administrative agreement governing the performance and fees associated with executing those changes.

Account and Contact Information

Effective Date of Address Change:

Name Change Details

Marriage Certificate
Court Order / Name Change Decree
Government-Issued ID
Other:

Scope of Services

The Service Entity will, upon receipt and verification of required documentation, update the Client's records to reflect the new address and/or legal name, and will take administrative steps reasonably necessary to effect the change, including notifying third parties listed by the Client if so authorized below. Specific tasks to be performed:

Client authorizes Service Entity to notify:

Payment Terms

Fee for services: $ payable as follows:

Late payment: If any payment is not received within days after the due date, a late fee of will apply and interest will accrue at the lesser of the statutory maximum or per month.

Term and Termination

Term Commencement Date:    Term Expiration Date (if any):

Either party may terminate this agreement for convenience upon written notice delivered not less than days prior to the effective termination date. Termination does not relieve Client of obligations to pay for services performed through the effective date of termination.

Confidentiality

Each party shall keep confidential all non-public information obtained from the other party in connection with this form and shall not disclose such information to any third party except: (a) as required by law or court order; (b) to its legal or financial advisors who are bound by confidentiality; or (c) with the prior written consent of the disclosing party. Confidential information excludes information that is or becomes publicly available other than through a breach of this provision.

Governing Law; Entire Agreement

This form shall be governed by and construed in accordance with the laws of the State of without regard to its conflict-of-law principles.

This document constitutes the entire agreement between the parties concerning the subject matter herein and supersedes all prior written or oral agreements and understandings related to the Client's address and name changes. Any amendment must be in writing and signed by both parties.

Certification and Authorization

By signing below, the Client certifies under penalty of perjury that the information provided on this form is true, correct and complete to the best of the Client's knowledge; that the supporting documentation submitted (or to be submitted) is genuine; and that the Client authorizes Service Entity to make the requested changes and to charge the fees set forth above.

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