DATE OF REQUEST: _____________________

TO: OFFICE OF THE TAX COLLECTOR/ASSESSOR

FROM: _______________________________

RE: REQUEST FOR ADDRESS OR NAME CHANGE

BLOCK__________ LOT__________PROPERTY LOCATION_____________

DEED DATE___________ BOOK______________PAGE__________________

I hereby request that the mailing address for the above listed Block and Lot be changed

TO:

_______________________________

_______________________________

_______________________________

________________________________

I hereby request that the name listed in the Tax Book be corrected to read:

________________________________

________________________________

Please print

Any additional Block and Lots affected by this change are listed below:

BLOCK______________ LOT________________

BLOCK______________ LOT________________

_______________________________________

Signature of requestor

_______________________________________________________________________________