Form Proc0037 – Fill Out and Use This PDF

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This form will allow you to transfer billing responsibilities for a Verizon Wireless mobile telephone number currently held by you to your employer

1)Complete all the applicable fields below.

2)If you are eligible, or required, to change your calling plan (or if the line you are transferring is the primary line on a Family SharePlan, or is the only secondary line on a Family SharePlan), please review the available calling plans on the Verizon Wireless website at verizonwireless.com. After selecting a calling plan, complete the fields in the Calling Plan Change section below.

3)Read the terms and conditions of this Transfer of Billing Responsibilities Form.

4)When returning this form via e-mail you must click the box above the signature line below to acknowledge your electronic acceptance of these terms. Save a copy of the form and upload it to the Verizon Wireless Secure Document Gateway at https://b2b.verizonwireless.com/tbmb/formuploader (address must be manually typed in to your browser). The form should then be e-mailed to GovernmentAccountSupport@verizonwireless.com from the Secure Document Gateway. E-mails will only be accepted from your Organization’s email domain. Once the form is received, a confirmation e-mail notice will be sent to the requester’s e- mail box.

5)If e-mail process is not available, return this form via Fax, have both parties sign and print at the bottom of this form and fax this form to:

240-568-1884

Note: Completion timelines for the Assumption of Liability request is 3-5 business days.

Account Information (Relinquishing Customer)

Wireless Number to be Transferred:	Existing Account Number:		Current Calling Plan:
Relinquishing Customer’s Name:		Relinquishing Customer’s e-mail Address:
Relinquishing Customer’s Billing Address: (No PO Boxes)		City:		State:		Zip Code:
		Relinquishing Customer’s Phone			Relinquishing Customer’s Employee I.D.
Billing Address (Cont):		Number:			(if applicable):

Calling Plan Change - If Required (Assuming Customer)

Personal/Employee Release of Liability (Relinquishing Customer)

•The account identified must be current (past due balance) before Verizon Wireless can transfer it to another party.

•Upon completion of the transfer of liability, Verizon Wireless will send you a final bill for all charges due through the date of the transfer of liability. You will be responsible for the payment of this final bill subject to the terms and conditions of your Customer Agreement and it will serve as your only notice of the transfer of liability.

•In addition to assigning all billing responsibilities to your Organization, all calling information associated with this mobile telephone number will become the property of Organization.

•By signing this form, or checking the box below, you agree to release liability for the mobile telephone number indicated above.

If you received this form electronically and are returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these terms.

Organization Assumption of Liability (Assuming Customer)

•The individual signing this Transfer of Liability on behalf of Organization represents that they have the legal capacity to bind Organization.

•By signing this form, or checking the box below, Organization agrees to assume liability for the mobile telephone number indicated above. (if returning via email, the Organization representative must include their name and date)

•Upon processing of the transfer of billing responsibilities, Organization will be solely responsible for all financial responsibility for this mobile telephone number.

•Subject to the existing line term, this line of service may be subject up to a $175 Early Termination Fee pursuant to the terms and conditions of Organization’s Agreement with Verizon Wireless.

•This Transfer of Billing Responsibilities is subject to Organization’s Agreement with Verizon Wireless.

	If you received this form electronically and are returning via e-mail, please check the box to the left to acknowledge your
	electronic acceptance of these terms.
	Signed:				Print Name:				Date:
	Organization Name:				Title:
	Billing Address: (No PO Boxes) Procurement/R&D Campus				E-mail Address:			Phone Number:
					Assuming Organization Tax ID #:			Number of Years in Business:
	Billing Address (Cont): ATTN: Accounts Payable
				Zip Code: 11794-	Create New Billing Account Number:			Add to existing Billing Account (if
	City: Stony Brook	State: NY		6000	Yes	No		applicable):
	Primary User’s Business Address (if different than billing):
	Note: No P.O. Boxes				City:		State:			Zip:
	PROC0037 (06/14)							www.stonybrook.edu/procurement