CHANGE OF ADDRESS FORM FOR NDC SERVICES

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CHANGE OF ADDRESS FORM – FOR NDC SERVICESFacility ID #If completing manually, please PRINT all information legibly.Facility Name:Tax ID#:Effective ** Resident Statements will be printed with the Facility Physical Address.**** Facility Physical Address is the default address used for ALL items unless specified below.**Street:AlternateAddress(if needed)City/State/Zip:Apply ONLY to marked items below:Resident StatementsResident Statement Shipping AddressResident 1099 StatementsMiscellaneousChecks - Address Printed on ChecksCheck Shipping Address (Street Address Only)InvoicesSupplies/OneWrite/Check-Order Invoices**Bank Statements for Atlantic Union Bank, Bank of America, Citibank, PNC Bank, Regions, TD Bank– Complete Page 2**Bank Statements for Chase Bank – Complete Page 3**Bank Statements for Capital One – Complete Capital One Maintenance Form (page 4)Street:AlternateAddress(if needed)City/State/Zip:Apply ONLY to marked items below:Resident StatementsResident Statement Shipping AddressResident 1099 StatementsMiscellaneousChecks - Address Printed on ChecksCheck Shipping Address (Street Address Only)InvoicesSupplies/OneWrite/Check-Order Invoices**Bank Statements for Atlantic Union Bank, Bank of America, Citibank, PNC Bank, Regions, TD Bank– Complete Page 2**Bank Statements for Chase Bank – Complete Page 3**Bank Statements for Capital One – Complete Capital One Maintenance Form (page 4)Authorization:Account Holder Signature:Date:If NDC has any questions on this form, they should contact:Contact Name:Contact Phone:Contact Email:Please upload to RFMS Document Portal http://rfmsdocs.com or send to [email protected]

CHANGE OF ADDRESS – FOR BANK SERVICESBank Statements for: Atlantic Union Bank Bank of America Citibank PNC Bank Regions TD BankFacility ID #If completing manually, please PRINT all information legibly.Facility Name:Tax ID#:Effective Date:Street:NewAddressCity/State/Zip:Apply to marked items belowFacility Physical AddressMailing AddressApply ONLY to marked items below:Bank StatementsResident Trust Statement Acct #Care Cost/Disbursement Acct #Petty Cash Acct #Account NumberAuthorization:Account Holder Signature: Date:Atlantic Union, Bank of America, Citibank, Regions, TD Bank– must be signer from signature card for account listedCapital One Bank DO NOT complete this page, complete page 4Chase Bank – DO NOT complete this page, complete page 3PNC Bank - must be signed by authorized individual per Resolution 3C SignatureIf NDC has any questions on this form, they should contact:Contact Name:Contact Phone:Contact Email:Please upload to RFMS Document Portal http://rfmsdocs.com or send to [email protected]

CHANGE OF ADDRESS – FOR BANK SERVICESBank Statements for: Chase Bank onlyFacility ID #If completing manually, please PRINT all information legibly.Facility Name:Tax ID#:Effective Date:Street:New MailingAddressCity/State/Zip:Apply ONLY to marked items below:Bank StatementsResident Trust Statement Acct #Care Cost/Disbursement Acct #Petty Cash Acct #Account NumberAuthorization:Account Holder Signature: Date:Complete this page for mailing address changes ONLY and must be signed by signer from signature card for account listedFor physical address change, a signed letter with Company letterhead signed by signer on signature card is requiredIf NDC has any questions on this form, they should contact:Contact Name:Contact Phone:Contact Email:Please upload to RFMS Document Portal http://rfmsdocs.com or send to [email protected]

NAME/ADDRESS/SOCIAL SECURITY NUMBERMAINTENANCE FORMREGION: VIRBRANCH\DEPT:COMM PRIVATE BKNG VA-GOV CNTRCTITLE/ADDRESS:OFFICER:08605TIN:PHONE:PLACE OF LEGAL ORGANIZATION:COUNTRY:COUNTRY:STATE:PLACE OF HEADQUARTERS:COUNTRY:STATE:INDUSTRY CATEGORY:TIER 1:TIER 2:TIER 3:COMMERCIAL CONTACT INFORMATION:CONTACT NAME:TITLE:PHONE:BUSINESS TYPE:# EMPLOYEES:SALES VOLUME:EMAIL ADDRESSES:PRODUCT:ACCOUNT ADDRESS:PRODUCT:ACCOUNT NUMBER:ACCOUNT NUMBER:BUSINESS:BUSINESS:PRODUCT:ACCOUNT ADDRESS:PRODUCT:ACCOUNT NUMBER:ACCOUNT NUMBER:BUSINESS:BUSINESS:PRODUCT:ACCOUNT ADDRESS:PRODUCT:ACCOUNT NUMBER:ACCOUNT NUMBER:BUSINESS:BUSINESS:CUSTOMER'S SIGNATURE (Authorized signer OR member/owner/secretary/partner)DATE: 09/17/201081IM2CE (9/08) 820124TIME: 11:15:40 AMProducts and services offered by Capital One, N.A., Member FDIC. Capital One Bank is atrade name of Capital One, N.A., and does not refer to a separately insured institution.ACCOUNT ADDRESS:ACCOUNT ADDRESS:ACCOUNT ADDRESS:BANK REPRESENTATIVE'S SIGNATUREUSER ID: NXS082P

**Bank Statements for Atlantic Union Bank, Bank of America, Citibank, PNC Bank, Regions, TD Bank– Complete Page 2 **Bank Statements for Chase Bank – Complete Page 3 **Bank Statements for Capital One – Complete Capital One Maintenance Form (page 4) Ap