"Address Change Request Form" - Kentucky

Address Change Request Form is a legal document that was released by the Kentucky Labor Cabinet - a government authority operating within Kentucky.

Form Details:

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Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Labor Cabinet.

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Download "Address Change Request Form" - Kentucky

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Matt Bevin
Kentucky Labor Cabinet
Derrick K. Ramsey
Governor
Division of Workers’ Compensation Funds
Secretary
657 Chamberlin Avenue
Jenean Hampton
William Emrick
Frankfort, Kentucky 40601
Lt. Governor
Acting Commissioner
Phone: (502) 564-5467
Fax: (502) 564-5112
Judith Erickson
www.labor.ky.gov
Director
ADDRESS CHANGE REQUEST FORM
Please fill out all information completely. Sign, date and mail form to: Kentucky Labor Cabinet, Division
of Worker’s Compensation Funds, 657 Chamberlin Avenue, Frankfort, KY 40601. Please allow up to 4
weeks for the address change to take effect.
CLAIM NUMBER: _________________________
CLAIMANT’S NAME: ______________________SS#_________________________
OLD ADDRESS: ____________________________________________________________
____________________________________________________________
NEW ADDRESS _____________________________________________________
_________________________________________________________
TELEPHONE NUMBER: (
) ___________________________________________
SIGNATURE OF CLAIMANT: ____________________________ DATE: _____________
COMMONWEALTH OF KENTUCKY )
)
COUNTY OF _____________________)
Subscribed and sworn before me, I __________________________________________, a Notary
Public, in and for the County and State above, do hereby declare that the Affiant,
__________________________________________________________________did appear personally
before me and furnish adequate identification of identity and stated that _______________(he/she)
did sign this document of Claimant’s own free will, on this the _____ day of _________________, 20__.
(AFFIX SEAL)
________________________________
Notary Public
My Commission expires: ____________
An Equal Opportunity Employer M/F/D
Matt Bevin
Kentucky Labor Cabinet
Derrick K. Ramsey
Governor
Division of Workers’ Compensation Funds
Secretary
657 Chamberlin Avenue
Jenean Hampton
William Emrick
Frankfort, Kentucky 40601
Lt. Governor
Acting Commissioner
Phone: (502) 564-5467
Fax: (502) 564-5112
Judith Erickson
www.labor.ky.gov
Director
ADDRESS CHANGE REQUEST FORM
Please fill out all information completely. Sign, date and mail form to: Kentucky Labor Cabinet, Division
of Worker’s Compensation Funds, 657 Chamberlin Avenue, Frankfort, KY 40601. Please allow up to 4
weeks for the address change to take effect.
CLAIM NUMBER: _________________________
CLAIMANT’S NAME: ______________________SS#_________________________
OLD ADDRESS: ____________________________________________________________
____________________________________________________________
NEW ADDRESS _____________________________________________________
_________________________________________________________
TELEPHONE NUMBER: (
) ___________________________________________
SIGNATURE OF CLAIMANT: ____________________________ DATE: _____________
COMMONWEALTH OF KENTUCKY )
)
COUNTY OF _____________________)
Subscribed and sworn before me, I __________________________________________, a Notary
Public, in and for the County and State above, do hereby declare that the Affiant,
__________________________________________________________________did appear personally
before me and furnish adequate identification of identity and stated that _______________(he/she)
did sign this document of Claimant’s own free will, on this the _____ day of _________________, 20__.
(AFFIX SEAL)
________________________________
Notary Public
My Commission expires: ____________
An Equal Opportunity Employer M/F/D