Address Change Form Michigan State Disbursement Unit Department of Human Services This form is to be used to notify the MiSDU of a change of address. Check the appropriate box, complete and return to the address noted on the form. My Name (Please print using black or blue ink): Last First Middle Phone Numbers: Home Phone Work Phone Other Phone Current/New Address: Number/Street/Apt. Number Social Security Number: City State/ZIP Date of Birth: Country (if not U.S.) Case ID or Docket Number: Number County Check the appropriate box: ! I am requesting a change of address for my mailing address. ! I am requesting a change of address for my residential address. ! I am requesting a change of address for both my mailing and residential addresses. Sign Here: Date: I declare that the information provided above is true and correct to the best of my knowledge. I understand that I must still change my address with the post office and the Friend of the Court office or I will not receive important legal documents. I understand that this notification must be in writing. Mail or fax this form to: MiSDU Attn: Address Change P.O. Box 30354 Lansing, MI 48909-7854 FAX: 517-318-4697 Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. Legal Authorities: 45 CFR 307.10 Completion: Voluntary DHS 1376 (8-06) MS Word AT 2006-022 Attachment 2 American LegalNet, Inc. www.FormsWorkflow.com