NAME CHANGE REQUEST With this Name Change Request form

» NAME C HANGE R EQUEST
PAGE 1 OF 2
With this Name Change Request form, you will be able to change the name as it
appears on your account*. Request a change for primary account holder, joint
account holder, or beneficiary.
NAME CHANGE
TPrimary Account Holder
TAdditional Account Holder
TBeneficiary
PRIMARY SIGNER (ACCOUNT HOLDER) UPDATE
Last Name
Social Security Number
First Name
-
-
Middle Initial
Identification Number
Issued By
Issue Date (If applicable)
Expiration Date
JOINT SIGNER (ACCOUNT HOLDER) UPDATE
Last Name
Social Security Number
First Name
-
-
Middle Initial
Identification Number
Issued By
Issue Date (If applicable)
Expiration Date
BENEFICIARY UPDATE
Last Name
Social Security Number
First Name
-
-
Middle Initial
Identification Number
Issued By
Issue Date (If applicable)
Expiration Date
ACCOUNT INFORMATION (PLEASE LIST ACCOUNT NUMBERS)
#
#
#
#
#
#
Does This account have a credit/debit card?
TYes
TNo
Do you have a safe deposit box with Flagstar?
TYes
TNo
flagstar.com
Card Number
Member FDIC
Rev 12/11
» NAME C HANGE R EQUEST
PAGE 2 OF 2
Primary Signature
Date
Joint Signature
Date
*Attach copies of legal documents authorizing name change.
IMPORTANT INFORMATION
Once complete and signed, please mail or fax to:
Mail: Flagstar Bank | Attn.: Internet Banking, Mail Stop 4-323 | 301 W. Michigan Avenue | Jackson, MI 49201
flagstar.com
Fax: (248) 250-5551
Member FDIC
Rev 12/11