* indicates a required field

2. City of Blythe
   Utility Billing Department
   CHANGE OF MAILING ADDRESS
   235 N Broadway Blythe, 92225
   760-922-6161 Ext 1233 or 1234
4. CUSTOMER SERVICE INFORMATION
6. Last Four Digits of SSN*

   ^{This information is used internally to verify the identity of the Account Holder/Customer}

8. Customer Name*
10. Service Address*
12. Service Account #:*
13. Contact Phone #
14. Contact Phone # Type
    -- Select One --CellHomeWork
16. Old Mailing Address*

    (if different from Service Address)

18. New Mailing Address*
20. Customer Signature*

    ‎A signature is required to process your request. By entering your valid email address in the box below you are signing this form and confirming that the above information is correct.

21. Date*
    Date
23. ‎

    FOR OFFICE USE ONLY
    Completed By	Date Completed

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24. 1. Receive an email copy of this form.
25. Email address

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