US POSTAL SERVICE - CHANGE OF ADDRESS ORDER - PS Form 3575-WWW [Postmasters, CFS managers, Carriers: Authorized for Official Use

-- DMM Issue 51, 01-01-97, F020.] OFFICIAL USE ONLY Zone / Route ID No. Date Entered on Form 3982 Expiration Date Carrier/Clerk Endorsement ___________ ____ ___/ ___/___ ___/ ___/___ ________ _______

Change of Address for: FAMILY Date to Begin Forwarding Mail: 11/13/2011 Is This Move Temporary?:No Title: First Name or Initial: Ben Middle Name or Initial: Last Name: Gridley Suffix: OLD ADDRESS Urbanization Name : N/A Mailing Address : 8817 CHINOOK DR City, State, ZIP+4: CHEYENNE WY 82009-8712 NEW ADDRESS Urbanization Name : N/A Mailing Address : 111 N 460 E City, State, ZIP+4: EPHRAIM UT 84627-1215 Signature of person who PREPARED this form: ___________________________________________________ Date Signed : ____/____/____ Name of Preparer Daytime Phone Email Address : Ben Gridley : (307) 222-9656 : bgridley@gmail.com Evening Phone : N/A

OFFICIAL USE ONLY Verification Endorsement [

***Give this form to your letter carrier or mail it to the address below:*** CHANGE OF ADDRESS ORDER ATTN: CARRIER ROUTE # R007 UNITED STATES POSTAL SERVICE 4800 CONVERSE AVE CHEYENNE WY 82009-9998 NOTE: The person signing this form states that he or she is the person, executor, guardian, authorized officer, or agent of the person for whom mail would be forwarded under this order. Anyone submitting false or inaccurate information on this form is subject to punishment by fine or imprisonment or both under Sections 2, 1001, 1702 and 1708 of Title 18, United States Code. PRIVACY NOTICE: This information you provide will be used to forward your mail to a new location. Collection is authorized by 39 USC 404. Filing this form is voluntary, but we cannot forward your mail without it. We do not disclose your information, except in the following limited circumstances: to government agencies or bodies as required to perform official duties; to mailers, only if they already possess your old address; in legal proceedings or for service of process; to law enforcement as needed for a criminal investigation; or to contractors who help fulfill the service.