Request Address Information Form – Fill Out and Use This PDF

PostmasterDate:_______________

___________________________

City, State, Zip Code

Request for Change of Address or Boxholder

Information Needed for Service of Legal Process

Please furnish the new address or the name and street address (if a boxholder) for the following:

NAME:___________________________________________________________________________________

ADDRESS:_______________________________________________________________________________

NOTE: The name and last known address are required for change of address information.

The name, if known, and post office box address are required for boxholder information.

The following information is provided in accordance with 39 CFR 265.6 (D)(6)(ll). There is no fee for providing boxholder information. The fee for providing change of address information is waived in accordance with 39 CFR 265.6(d)(1) and (2) and corresponding Administrative Support Manual 352.44a and b.

1.Capacity of requester (e.g., process server, attorney, party representing himself:________________________________________

2.Statute or regulation that empowers me to serve process

(not required when requester is an attorney or a party acting pro se –

except a corporation acting pro se must cite statute):__________________________________________________________________

3.The names of all known parties to the litigation:_________________________________________________

4.The court in which the case has been or will be heard:____________________________________________

5.The docket or other identifying number if one has been issued:_____________________________________

6.The capacity in which the individual is to be served ( e.g. defendant of witness):___________________________________

WARNING

THE SUBMISSION OF FALSE INFORMATION EITHER (1) TO OBTAIN AND USE CHANGE OF ADDRESS INFORMATION OR BOXHOLDER INFORMATION FOR ANY PURPOSE OTHER THAN THE SERVICE OF LEGAL PROCESS IN CONNECTION WITH ACTUAL OR PROSPECTIVE LITIGATION OR (2) TO AVOID PAYMENT OF THE FEE FOR CHANGE OF ADDRESS INFORMATION COULD RESULT IN CRIMINAL PENALTIES INCLUDING A FINE UP TO $10,000 OR IMPRISONMENT OF NOT MORE THAN 5 YEARS, OR BOTH (TITLE 18 U.S.C. SECTION 1001)

I certify that the above information is true and that the address information is needed and will be used solely for service of legal process in connection with actual or prospective litigation.

__________________________________	_______________________________
Signature	Address
__________________________________________	______________________________________
Printed Name	City, State, Zip Code

	FOR POST OFFICE USE ONLY
No change of address order on file.
	Postmark
Not known at address given.	NEW ADDRESS OR BOXHOLDER’S NAME
	AND STREET ADDRESS
Moved, left no forwarding address.	_____________________________________
	_____________________________________
No such address.	_____________________________________