FIRST NAME MIDDLE INITIAL
LAST NAME
E-MAIL
PHONE  (XXX) XXX-XXXX or XXX-XXX-XXXX
CASE NAME
CLAIM NUMBER (IF KNOWN)
OLD ADDRESS
ADDRESS 1
ADDRESS 2
CITY STATE    ZIP 
PROVINCE    If non-U.S. address
COUNTRY
NEW ADDRESS
ADDRESS 1
ADDRESS 2
CITY STATE     ZIP
PROVINCE    If non-U.S. address
COUNTRY
Bold = Required Field