American Express Name Change 4l5u5i

Print Form

Name Change Authorization I request American Express to change the name on my Card (s) listed below and issue me a Card in the new name I have printed below for each such . Please use this new name when issuing renewal and replacement Cards for the (s). I understand that American Express will cancel any outstanding Card(s) in my former name, and I agree to destroy any Card(s) I have in my former name. Number(s): 37119023041003

(Name is limited to a total of 20 characters including spaces. Please abbreviate where required)

Veronica Donofrio Original Name

X Original Signature

4/26/13 Date

Veronica Kotulak New Name

X New Signature

4/26/13 Date

Complete only if address change is required: Billing Address

Apt Number/Company Name (If applicable)

Street Address

City/State

Zip Code

Phone: Home

Work

Please the completed form electronically at Americanexpress.com/documentcenter using the Name Change Authorization as the Document Category, along with a copy of your State Issued Identification Card or Drivers License or U.S. port reflecting your new name. Only the following file types can be ed: .PDF, .DOC, .DOCX, .TIF, .JPEG, .BMP, .GIF. You can also send this form to: American Express, PO Box 981540, El Paso, TX 79998-1540 OR

Fax at 623-444-3000 NCAF- (Rev.2012-02-16)