Form DFS-N1-1704 "Change of Mailing Address or Contact Data - Individuals" - Florida

What Is Form DFS-N1-1704?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DFS-N1-1704 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-N1-1704 "Change of Mailing Address or Contact Data - Individuals" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Funeral, Cemetery & Consumer Services
200 East Gaines Street
Tallahassee, FL 32399- 0361
Change of Mailing Address or Contact Data -- Individuals
INDIVIDUAL applicants and licensees use this form to notify the Division of Funeral, Cemetery &
Consumer Services of changes in their address or other contact data. ENTITIES SHOULD NOT USE
THIS FORM. When completed, mail this form to the Division at the address shown above. There is no fee.
Section 1. LICENSEE INFORMATION
Please provide all data requested in this Section so that we can accurately identify the record to be updated.
First name:
Middle name (leave blank if none):
Last name:
Name Suffix (examples: Jr., II) (leave blank if none):
Birth Date (mm/dd/yyyy):
/
/
Existing licensees only -- if you are an existing licensee, enter your license number in this
block:
License applicants only -- if you are an applicant for a license, indicate what month and year
you submitted your application and for what type of license you applied:
Month
Year
Type of License
Section 2. NEW ADDRESS AND/OR OTHER CONTACT DATA
You may leave blank any data field where no updating is needed. However, if you are in doubt as to what
data the Division has concerning you, feel free to enter data in all data fields below.
Residence address
(no P.O. boxes allowed here)
Street:
City:
State:
Zip:
Country:
Preferred Mailing Address
Street:
City:
State:
Zip:
Country:
Business Location Address
Street:
City:          
State:           Zip:
Country:
Best Phone number to contact you
Email address (e.g., smithj@xyz.com)
Area code
Phone #
-
Form DFS-N1-1704; Change of Mailing Address of Contact Data-Individuals
1 of 2
(Rev. 07/12); 69K-1.001
Page
DEPARTMENT OF FINANCIAL SERVICES
Division of Funeral, Cemetery & Consumer Services
200 East Gaines Street
Tallahassee, FL 32399- 0361
Change of Mailing Address or Contact Data -- Individuals
INDIVIDUAL applicants and licensees use this form to notify the Division of Funeral, Cemetery &
Consumer Services of changes in their address or other contact data. ENTITIES SHOULD NOT USE
THIS FORM. When completed, mail this form to the Division at the address shown above. There is no fee.
Section 1. LICENSEE INFORMATION
Please provide all data requested in this Section so that we can accurately identify the record to be updated.
First name:
Middle name (leave blank if none):
Last name:
Name Suffix (examples: Jr., II) (leave blank if none):
Birth Date (mm/dd/yyyy):
/
/
Existing licensees only -- if you are an existing licensee, enter your license number in this
block:
License applicants only -- if you are an applicant for a license, indicate what month and year
you submitted your application and for what type of license you applied:
Month
Year
Type of License
Section 2. NEW ADDRESS AND/OR OTHER CONTACT DATA
You may leave blank any data field where no updating is needed. However, if you are in doubt as to what
data the Division has concerning you, feel free to enter data in all data fields below.
Residence address
(no P.O. boxes allowed here)
Street:
City:
State:
Zip:
Country:
Preferred Mailing Address
Street:
City:
State:
Zip:
Country:
Business Location Address
Street:
City:          
State:           Zip:
Country:
Best Phone number to contact you
Email address (e.g., smithj@xyz.com)
Area code
Phone #
-
Form DFS-N1-1704; Change of Mailing Address of Contact Data-Individuals
1 of 2
(Rev. 07/12); 69K-1.001
Page
Section 3. SIGNATURE OF LICENSEE
I, the licensee or applicant identified above, hereby request the Division of Funeral, Cemetery &
Consumer Services to conform the data in their records concerning my address and other
contact data to the information entered above.
___________________________________
________________________
Licensee signature
Date signed
Section 4.
SOCIAL SECURITY NUMBER
Enter Licensee’s Social Security Number:             
Purpose and Use:
The collection of social security numbers on applications for licensure under Chapter 497 is expressly authorized by s.
497.141(2), Florida Statutes. Social security numbers collected on applications will be used by the Department of Financial
Services and the Board of Funeral, Cemetery and Consumer Services as follows: identification of applicants; obtaining
background checks on applicants; obtaining information from authorities in other states; investigation of applicants and
licensees concerning asserted violations of applicable law or rules; enforcement of child support obligations. The social
security number may also be used for any other purpose required or authorized by federal or Florida Law.
Form DFS-N1-1704; Change of Mailing Address of Contact Data-Individuals
2 of 2
(Rev. 07/12); 69K-1.001
Page
Page of 2