Customer Contact Update Form printable pdf download

Customer Contact Update Form

IN.gov Account Number:_____________________________________________________

Name of Business:__________________________________________________________

Customer Contact Update

Current administrator name:________________________ Delete user from account? Yes ___No___

New administrator name:_____________________________ Current user on account? Yes___ No___

If no, this contact will automatically be added as a user on your account.

New administrator email address:______________________________________________________

New administrator signature:__________________________________________________________

Is this a co-customer contact? Yes___ No___ If yes, note that only one customer contact can receive

email account notifications. Please list below the customer contact that is to receive account

notifications : ______________________________________________

Responsibilities of the Account Administrator



Notify IN.gov of all changes on account

o Addition/Deletion of users

o Address change

o Billing information change



Insure usernames and passwords are not shared. It is in violation of the account agreement to

do so.



IN.gov will only discuss account information with the Account Administrator.

Date:____________________________

151 W. Ohio St, Suite 100

Indianapolis, IN 46204

1.888.4IN.eGov

Fax: 317.233.2011

customerservice@

Customer Contact Update Form