Address Change Request

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If you have questions or need assistance filling out this form, please call 217.342.4101 and ask for the Credit Department

*Account Name:
Please type the account name exactly as it appears on your account statements and invoices
*Account Number:
*New Billing Address:
*New Billing City:
*New Billing State:
*New Billing Zip Code:
*New Billing Phone Number:
*Person Requesting Change:
For documentation purposes we need to know who is requesting the change. If you are the account owner, please type your name and account owner. For example, "Joe Smith, Account Owner". If you are the power of attorney for a parent or other individual, please type your name and power of attorney for account owner. For example, "Joe Smith, Power of Attorney for Jane Smith".
*Email Address:
Please include your email address, so we can follow up and let you know the change has been completed, or if there is any discrepancies.
*Reason for Request:
*Security Code: