Record

Change-of-address payment form

A blank change-of-address form to be returned with payment, with no completed fields.Machine-written summary

EFTA00123937¶

PLEASE DETACH AND RETURN THE PORTION BELOW WITH YOUR PAYMENT¶

CHANGE OF ADDRESS¶

(Please print using blue or black ink)¶

Current Address:¶

BROOKLYN, NY 11234-4029¶

New Address¶

City	State	Zip

Home Phone¶

Alternate Phone¶

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