Electronic Change Of Address Form Page 2
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1
2ELECTRONIC CHANGE OF ADDRESS FORM
I,
____________________________,
authorize
Chesapeake
Operating,
L.L.C.
and/or
its
affiliates/subsidiaries to change the address on my owner account.
Owner Number: ______________
CHK Lease Number: _____________________
Last 4 Digits of Social Security # / Taxpayer ID: ____________________________
(Your Owner Number is listed under the name and address section of your revenue check stub)
Name on the Account: ____________________________________________________________________
Your Name (if you are not the owner): ________________________________________________________
(If not previously provided, please attach documentation establishing your relationship with the Account Owner for Chesapeake’s
review.)
OLD ADDRESS
NEW ADDRESS
Address
Address
City/Locality/Village
City/Locality/Village
State/Province/Region
State/Province/Region
Zip
Zip
Country
Country
Phone
Email
Apply this address change to my:
Check/Revenue Address
Correspondence Address
If neither box is selected, both addresses will be updated.
All fields must be complete or the change of address cannot be processed. After Chesapeake’s receipt and approval,
the change of address will become effective within thirty (30) days.
TERMS OF ACCEPTANCE & SIGNATURE
I, the requestor for this Change of Address Form, warrant the truthfulness of the information provided in this submission. I
.
understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature
Step 1: Check the box below
*By checking this box and typing my name below, I am electronically signing this Change of Address Form
Step 2: Type in your name in the boxes below. A signature is required by all parties listed on the account.
___________________________
___________
_________________________
_____________
First Name
Middle Initial
Last Name
Suffix
___________________________
___________
_________________________
_____________
First Name
Middle Initial
Last Name
Suffix
Email this completed form to:
Customer Reference ID#_______________
Form ID: eCOA 2016-02
(for internal use only)
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