US POSTAL SERVICE - CHANGE OF ADDRESS ORDER - PS Form 3575-WWW
[Postmasters, CFS managers, Carriers: Authorized for Official Use -- DMM Issue 51, 01-01-97, F020.]
OFFICIAL USE ONLY
Zone / Route ID No. ___________ ____
Date Entered on Form 3982 ___/ ___/___
Expiration Date ___/ ___/___
Carrier/Clerk Endorsement ________ _______
Change of Address for: FAMILY
Date to Begin Forwarding Mail:
Is This Move Temporary?: No
Title:
First Name or Initial:
Middle Name or Initial:
Last Name:
Suffix:
OLD ADDRESS
Urbanization Name : N/A
Mailing Address :
City, State, ZIP+4: ,
NEW ADDRESS
Urbanization Name : N/A
Mailing Address :
City, State, ZIP+4: ,
Signature of person who PREPARED this form : ___________________________________________________
Date Signed : ____/____/____
Name of Preparer :
Daytime Phone : Evening Phone : N/A
Email Address :
OFFICIAL USE ONLY
Verification Endorsement [ ]
***Give this form to your letter carrier or mail it to the address below:***
CHANGE OF ADDRESS ORDER
ATTN: CARRIER ROUTE #
UNITED STATES POSTAL SERVICE
,
NOTE : The person signing this form states that he or she is the person, executor, guardian, authorized
officer, or agent of the person for whom mail would be forwarded under this order. Anyone submitting
false or inaccurate information on this form is subject to punishment by fine or imprisonment or both
under Sections 2, 1001, 1702 and 1708 of Title 18, United States Code.
PRIVACY NOTICE : This information you provide will be used to forward your mail to a new location.
Collection is authorized by 39 USC 404. Filing this form is voluntary, but we cannot forward your mail
without it. We do not disclose your information, except in the following limited circumstances: to
government agencies or bodies as required to perform official duties; to mailers, only if they already
possess your old address; in legal proceedings or for service of process; to law enforcement as needed
for a criminal investigation; or to contractors who help fulfill the service.