CHANGE OF INVESTOR ADDRESS
Sign and return original form to US Energy Development Corporation at 2350 N Forest Rd, Getzville NY 14068.
For assistance, please contact the Investor Relations desk at 800-636-7606 x349
A. INVESTOR INFORMATION
Investor(s) Name:
Social Security Number / TIN:
Note: U.S. Energy cannot accommodate time-specific address changes (Example: “We will only be at this address
from May-July.”) EACH TIME your address changes, U.S. Energy must receive a new form.
Please list programs invested in: ______
__________________
__________________
__________________
__________________
B. PRIOR ADDRESS
Street Address:
City:
State:
Zip:
State:
Zip:
C. NEW ADDRESS
Street Address:
City:
Phone Number(s):
D. SIGN YOUR NAME
I the undersigned hereby instruct U.S. Energy Development Corporation to change the information
listed above.
Signature: _______________________________________________________
Printed Name: _______________________________ Date: ________________
Rev. Date: 11/13
2350 North Forest Road, Getzville, New York 14068
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800-636-7606
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www.usedc.com