Change Of Information Form
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1March 2014
1
Change of Information Form
CHANGE OF NAME/ADDRESS/PHONE/EMAIL:
Note: If your name has changed, you must mail a copy of your new social security card in
your current legal name and a new W9 form in order to legally issue an incentive check.
Current Date:
__________________
Name:
________________________________________________________________________________
(Note: Name must match name on new Social Security Card and the name on the W9 form.)
Previous Name:
_________________________________________________________________________
Previous Home Address:
__________________________________________________________________
Previous Home City, State, Zip:
_____________________________________________________________
New
Home Address:
_____________________________________________________________________
New
Home City, State, Zip:
________________________________________________________________
New
Home Phone Number:
__________________________________
Previous Email Address:
_________________________________________________
New
Email Address:
_ ___________________________________________________
SUBMITTING FORM:
Mail Form and Supporting
Remember To Attach:
Documentation to:
□
Copy of social security card in your current
IdahoSTARS
Attn: PDS Registry
legal name (if name has changed)
4355 W Emerald St., Ste 250
□
W9 Form (if name has changed)
Boise, Idaho 83706-2072
4355 W. Emerald St., Ste 250
2-1-1 Idaho Careline
Boise, ID 83706
1-800-926-2588
Fax: 208-345-6569
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