Request for Change of Billing Address

    
(* = Required)W-613 7/10
* First Name:
 
* Last Name:
 
* Case Number:
 
*Last 4 digits of SSN:
*Date of Birth  MM/DD/YYYY):  
Old Address 
*Street Address
*City:
*State:
 
*Zip:

New Address 
*Street Address
*City:
*State:
 
*Zip:
*Telephone Number: (xxx-xxx-xxxx)
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. 

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.