Personal Address Change Request

Personal Address Change Request

Use this form to request an update of your mailing and residence address on file. Complete all applicable sections, sign and date at the end. Incomplete or inaccurate information may delay processing or result in rejection of the request.

A. Applicant Information

Date of Birth:    Account / ID Number:

B. Current Address on File

Primary residence    Mailing address only

C. New Address to Be Recorded

Effective date for this change:    Date moved (if already moved):

Update all accounts and records to the new address
Forward incoming mail to new address for 30 days
Update billing and statement address
Other (describe below)

D. Contact & Identification

ID Type:    ID Number:    Issuing State/Country:

E. Reason for Change

F. Certification and Authorization

I certify under penalty of law that the information provided on this form is true, complete, and accurate to the best of my knowledge. I am the individual named above or am authorized to act on behalf of that individual. I authorize this organization and its agents to update their records to reflect the new address and to take reasonable steps to verify the information provided. I understand that submitting false information may result in administrative action, including denial of the change and potential legal consequences.

By signing below, I authorize release of account-related communications to the new address and, where indicated above, the forwarding of mail. This authorization remains in effect until I submit a signed written revocation.

I certify that I am authorized to request this change and that I have read and understood the statements above.

G. Additional Instructions or Comments

H. Optional Witness Information

Witness Name (if available):    Witness Contact:

I. Internal Use Only

Date Received:    Records Updated:    Updated By:    Update Date:

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