CHANGE OF ADDRESS FORM Department of Criminal Records Circuit Court of Jackson County, Missouri Kansas City fax: (816) 881-3420 / Independence fax: (816) 881- 4691 Requestor’s Name ________________________________________________________________ Case Number ______________________________________________________________________ *I certify that I am the (check one): Defendant Victim Attorney Bond Assignee Other ___________________________ (*NOTE: You are not authorized to change any address other than your own.) OLD ADDRESS Street Address ___________________________________________________________________ City ________________________________________ State ___________ Zip _________________ NEW ADDRESS Street Address ___________________________________________________________________ City ________________________________________ State ___________ Zip _________________ Home Phone (____)_____________________ Mobile/Other Phone (____)________________ My case was heard in: Kansas City Independence I acknowledge that the above information is true and correct. _____________________________________________ __________________________ SIGNATURE OF REQUESTOR DATE If your case was heard in Kansas City, mail or fax to: Department of Criminal Records 1315 Locust Kansas City, MO 64106 (FAX) 816-881-3420 If your case was heard in Independence, mail or fax to: Department of Criminal Records 308 W. Kansas Suite 310 Independence, MO 64050 (FAX) 816-881-4691 09/05 American LegalNet, Inc. www.FormsWorkflow.com