Change of Address Form
Persons who have previously completed a Victim Impact Statement, Notification Request Form, or a written letter whose mailing address has changed should complete the information below.
INMATE INFORMATION
Offender Name *
Your answer
Offender Date of Birth
MM
/
DD
/
YYYY
Offender Gender *
Offense
Your answer
Conviction Date
MM
/
DD
/
YYYY
County of Conviction
Indictment Number
(if known)
Your answer
Offender GDC ID or Case Number
(if known)
Your answer
VICTIM INFORMATION
Victim Name *
Your answer
Person Requesting Information Change
(If different from victim)
Your answer
Person completing form relationship to victim *
PREVIOUS ADDRESS INFORMATION
Previous mailing address *
(Street # and name / P.O.Box #)
Your answer
City *
Your answer
State *
If you clicked on INTERNATIONAL please list the previous international address below
Your answer
Zip Code *
Your answer
Primary Telephone Number
(numbers only, no special characters, i.e 4046516668)
Your answer
Type of Primary Phone *
Secondary Telephone Number
(numbers only, no special characters, i.e 4046516668)
Your answer
Email Address
Your answer
NEW ADDRESS INFORMATION
New mailing address *
(Street # and name / P.O.Box #)
Your answer
New City *
Your answer
New State *
If you clicked on INTERNATIONAL please list the new address below
Your answer
New Zip Code *
Your answer
New Primary Telephone Number
Your answer
Type of New Primary Phone *
New Secondary Telephone Number
(numbers only, no special characters, i.e 4046516668)
Your answer
New Email Address
Your answer
If you require special accommodations in accordance with the Americans with Disabilities Act, please list below
(Americans with Disabilities Act (ADA))
Your answer
Submit
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