Housing Authority of the Town of Mansfield
309 Maple Road
Storrs, CT 06268
(860) 487-0693

To: Postmaster

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ADDRESS INFORMATION REQUEST
Please furnish this agency with the new address, if available, for the following individual or verify whether or not the address given below is one at which mail for this individual is currently being delivered. If the following address is a post office box, please furnish the street address as recorded on the box holder’s application form.  
 
Name: 			__________________________
Last Known Address: __________________________
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I certify that the address information for this individual is required for the performance of this Agency’s official duties.
Signature of Agency Official  __________________________
Title	                     __________________________
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{  } MAIL IS DELIVERED TO ADDRESS GIVEN ABOVE
{  } NOT KNOWN AT ADDRESS GIVEN ABOVE
{  } MOVED, LEFT NO FORWARDING ADDRESS
{  } NO SUCH ADDRESS
{_}OTHER,PLEASE_SPECIFY:_______________________________________
NEW ADDRESS ________________________________________________________________
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BOXHOLDER’S STREET ADDRESS
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COMPANY RETURN ADDRESS			POSTMARK/DATE STAMP