Address Change Request
Address Change Request
* Required Information
*Customer Number:
*Name (First MI Last):
*Street Address:
*City, *State, *Zip: ,
  Permanent or Temporary Address Change
If temporary, from / / to / /
New Address Information
*Address Line 1:
Address Line 2:
*City, *State, *Zip: ,
Home Phone: -
Work Phone: -
Fax Number: -    
*E-mail Address:
Would you like an e-mail from Midland States Bank verifying your address has been changed?
Yes   No
Please submit a separate Address Change form for each Customer number.