Providence Bank - Change of Address Form

DATE:

Change of Address Form

Customer Name: New Address:

City: State: Zip:

Old Address: City: State:

Zip: New Telephone number: -- Old Telephone number: --

List names of ALL account holders who are affected by this change: 1. 2. 3. 4.

Alternate Mailing Address:

*(Note: Use this section to add or change an alternate mailing address – e.g., winter or summer home, accountant, attorney, etc.)*
*Check One Box Below:*
Ongoing	Seasonal:
	From:
	To:

Street Address:

City:

State:

Zip:

Customer Signature: ____________________________________ Date:____/_____/____

List all loans/deposit accounts/debit cards to be changed:

FOR OFFICE USE ONLY

IN PERSON	No additional follow up
IN RETURNED MAIL Completed________________	Send change of address form	Signature Verified ___________________	Follow up with a phone call. ______________(INIT) or a letter if no response. Mail out return mail.
WRITTEN REQUEST Completed________________	Signature Verified ___________________	Follow up with a phone call. ______________(INIT) or a letter if no response.
PHONE REQUEST Completed________________	Send change of address form	Signature Verified ___________________	Follow up with a phone call. ______________(INIT) or a letter if no response.
INTERNET BANKING	Follow up with a phone call. ______________(INIT) or a letter if no response.
E-MAIL REQUEST	Send change of address form	Signature Verified ___________________	Follow up with a phone call. ______________(INIT) or a letter if no response.
Received By:			Date:
Entered By:			Date:
Verified By:			Date:

Print, Sign and Fax to 1-708-589-2913

For security reasons we do not recommended e-mailing this document.

Which branch will you mainly do business with (check only one)?

South HollandDyerMunsterElmhurstSchererville

*Account Number*	*Type (checking, savings, debit, loan, etc.)*	*Open or Closed*
		Open Closed
		Open Closed
		Open Closed
		Open Closed
		Open Closed