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2. 
4. Assessment Code*
5. Geocode*
7. Legal Owner Name*
9. Old Mailing Address*
11. City*
12. State*
13. Zip Code*
15. New Mailing Address*
17. City*
18. State*
19. Zip Code*
21. Last four digits of your SSN or FEIN*

23. By signing this form, I affirm I am the legal owner of the property record referenced above or have the authority to represent the property owner for this mailing address change request.

25. Property Owner or Representative Name (please print)*
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
31. Date*
32. Contact Phone*
34. Email Address*

36. For questions, call our local field office at (406) 780-6950.

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field