CHANGE OF PURCHASER
CURRENT PURCHASER’S NAME:
_________________________________
BENEFICIARY’S NAME:
_____________________________________________
PACT ACCOUNT NUMBER:
_______________________________________ _____
PACT HAS RECEIVED A REQUEST TO CHANGE PURCHASERS ON THE ABOVE REFERENCED
ACCOUNT (S). IN ORDER TO PROCESS THIS REQUEST, PLEASE COMPLETE THIS FORM AND REMIT
THE $20.00 ADMINISTRATIVE FEE (FEE IS WAIVED IF CHANGE IS DUE TO DEATH OF PURCHASER)
TO THE FOLLOWING ADDRESS: PACT PROGRAM, P O BOX 12865, BIRMINGHAM AL 35202-2865.
PLEASE PRINT
NEW PURCHASER’S NAME: ________________ ___ SSN: ______________________________
RELATIONSHIP TO CURRENT PURCHASER:____________________________________________
SIGNATURE:
DATE:
ADDRESS: __________________________________________________________________________
HOME PHONE: _______________________________ WORK PHONE: _______________________
TO AUTHORIZE THIS PURCHASER CHANGE, PLEASE SIGN THIS COMPLETED FORM IN THE PRESENCE
OF A NOTARY. IF PURCHASER IS DECEASED, PLEASE ATTACH A COPY OF THE LETTERS
TESTAMENTARY, LETTERS OF ADMINISTRATION OR THE APPROPRIATE PAGES FROM THE WILL
GIVING EVIDENCE OF APPOINTMENT AS EXECUTOR, AND THE DEATH CERTIFICATE.
__________________________________________
CURRENT PURCHASER’S SIGNATURE
STATE OF ALABAMA
EXECUTOR’S SIGNATURE (If Purchaser is deceased)
COUNTY OF
THE FOREGOING INSTRUMENT WAS
DATE
ACKNOWLEDGED BEFORE ME THIS
DAY OF
, 20
NOTARY PUBLIC, STATE OF ALABAMA