| REQUEST FOR CHANGE OF BILLING ADDRESS |
| (* = Required) |
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W-613 7/10
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* First Name:
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* Last Name:
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* Case Number:
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*Last 4 digits of SSN:
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*Date of Birth (MM/DD/YYYY):
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| Old Address |
*Street Address
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*City:
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*State:
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*Zip:
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New Address |
*Street Address
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*City:
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*State:
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*Zip:
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*Telephone Number: (xxx-xxx-xxxx)
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| In order to process your request, select “Confirm Request” from the drop-down box below. By clicking Submit, you are giving your express permission to formally change your billing address with the City of New York. |
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I hereby attest that I am the above stated individual and that I am authorized to complete the above referenced form and that the above is my current address. I understand that if I provide false information I may be liable for any penalty applicable under law, including possible loss of benefits.
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