Human Resources Administration311

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Request for Change of Billing Address

Please Enter Your Info

* - Indicates required fields

First Name: *

Last Name: *

Case Number: *

Last 4 Digits of SSN: *

Date of Birth: *

Old Address

Street Address: *

City: *

State: *

ZIP Code: *

New Address

Street Address: *

City: *

State: *

ZIP Code: *

Telephone Number (numerals only): *

In order to process your request, select "Confirm Request" from the drop-down box below. By clicking Submit, you are giving your express permission to formally change your billing address with the City of New York.

I hereby attest that I am the above stated individual and that I am authorized to complete the above referenced form and that the above is my current address. I understand that if I provide false information I may be liable for any penalty applicable under law, including possible loss of benefits.

Confirm Request: *

Please click on SUBMIT to send this information to HRA Claims and Collections