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ADDRESS CHANGE REQUEST FORM Please complete, print and mail this form to the address below. _____________________________________________________________________________________ First Name Middle Initial Last Name Social Security Number __________________________________________________________________ Home Phone ___________________________________ Mobile Phone __________________________________ Daytime Phone _________________________________ e-Mail Address _________________________________ If this is a joint account or a business account, please complete the following information: _____________________________________________________________________________________ First Name Middle Initial Last Name / Business Name Social Security Number ________________________________/ Federal ID Number ________________________________ Home Phone ______________________________________ Business Phone ___________________________________ Mobile Phone _____________________________________ Daytime Phone ____________________________________ e-Mail Address ____________________________________ New Address Information: ______________________________________________________________________ Street Address ______________________________________________________________________ City, State, Zip Is this a seasonal address? ___ Yes ___ No Is this a seasonal address that is recurring? If yes, from (date) _____________ to (date) ____________ ___ Yes ___ No Effective date of changes ____________________________ The account owner and joint account owner must sign. Please have the signatures notarized if mailing the form. ______________________________________________ Date _____________________________ ______________________________________________ Date _____________________________ Mail signed form to: westbury bank Customer Support 200 S. Main St. West Bend, WI 53095 NOTARY State of _________________________________ County of _______________________________ ________________________________________ (Signature) My commission expires: ___________________