Address Information Request Format - Government Agency
(Required Format Referenced at Paragraph 265.6(d)(5)(i) & (7))
 (AGENCY LETTERHEAD) 	
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To: 	Postmaster 	
	___________________________________________________ 	
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Agency Control Number _________________________________________________________ 	
Date _________________________________________________________________________ 	
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ADDRESS INFORMATION REQUEST 	
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Please furnish this agency with the new address, if available, for the following individual or verify whether or not the address given below is one at which mail for this individual is currently being delivered. If the following address is a post office box, please furnish the street address as recorded on the boxholder's application form. 	
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Name: ________________________________________________________________________ 	
Last Known Address: ____________________________________________________________ 	
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I certify that the address information for this individual is required for the performance of this agency's official duties. 
_____________________________________________________________________________ 	
(Signature of Agency Official) 	
_____________________________________________________________________________ 	
(Title) 	
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FOR POST OFFICE USE ONLY 	
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[ ] MAIL IS DELIVERED TO ADDRESS GIVEN 	NEW ADDRESS 	
[ ] NOT KNOWN AT ADDRESS GIVEN	 ________________________________ 	
[ ] MOVED, LEFT NO FORWARDING ADDRESS 	________________________________ 	
[ ] NO SUCH ADDRESS 	
[ ] OTHER (SPECIFY): 	BOXHOLDER'S STREET ADDRESS 	
______________________________________ 	________________________________ 	
______________________________________ 	________________________________ 	
Agency return address 	Postmark/Date Stamp 	
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