Instructions for
Change/Withdrawal Notice
Address Confidentiality Program (ACP)
This application should be used to make changes to application information submitted by the program. Program participants
should review the instructions below to ensure they understand how to properly complete the form if their information changes.
Section 1 - Type of Change
Depending on the type of change, the participant should check the applicable box which pertains to the change. A description of
what each of the boxes represent is below:
Primary Participant's Name Change - This box should be selected if the primary participant has changed his or her name
through a legal process in order to update the ACP with this new information. Participants should provide the updated name to
any government agencies or businesses to which they previously provided their name. Once ACP has processed this change,
program participants will receive an ACP identification card containing the new name.
Other Participant's Name Change - This box should be selected if other household participants have changed their names
through a legal process in order to update the ACP with this new information. Participants should provide the updated name to
any government agencies or businesses to which they previously provided their name.
Mailing Address Change - This box should be selected if the primary participant would like to change the address where
they want their mail sent. It is important that primary participants who change their mailing address notify the ACP as soon as
possible. If the program participant does not notify the ACP within 14 days of their change in mailing address and the mail is
returned non-deliverable, the program participant will be cancelled from the program.
Actual Address Change - This box should be selected if the program participant has changed where they actually live.
Withdrawal from Program Request - This box should be selected if the program participant or one of the other participants
wants to withdrawal from the program. The applicable participant will need to complete Section 3.
Section 2 - Change information
Complete the section that corresponds with the box selected above. The program participant should provide both the previous
information and the change in information.
Section 3 - Withdrawal Section
Check whether the primary participant or other household member participating in ACP wishes withdrawal from the program. If
both wish to withdrawal check both boxes. Print the full name of the participant who wishes to withdraw from the program. If the
primary participant withdrawals from the program, the entire record will be removed from the ACP and all other participants will
also be removed from the program.
Section 4 - Security Word
Provide the correct security word to ensure that only an authorized person is making changes to the record. If the participant
cannot remember the security word, they may contact the ACP for a hint.
Section 5 - Affirmation of Applicant
The primary participant (or his or her guardian) must sign and date the form affirming that the information provided is true and
correct. If the change being made is only to withdraw another adult participant from the program, the change form can be signed
either by that adult participant or the primary participant. The completed application form should be sent to the address indicated
on the application.
DOS-1931-f (Rev. 09/18) (form on next page) Page 1 of 2
NYS Department of State
Address Confidentiality Program
P.O. Box 1110
Albany, NY 12201-1110
Phone: (518) 474-7306
Toll Free: (855) 350-4595
Fax: (518) 474-0709
Email: [email protected]
Web: www.dos.ny.gov/acp
Change/Withdrawal Notice
Address Confidentiality Program (ACP)
Read instructions carefully before completing this application. Please PRINT or TYPE responses in ink.
SECTION 1: Type of Change - Please check appropriate box
Primary Participant's Name Change ACP Identification Number
Other Participant's Name Change
Mailing Address Change (where ACP sends the applicant's mail)
Actual Address Change (where applicant actually lives)
Withdrawal from Program Request ** Skip Section 2 if withdrawing **
SECTION 2: Change Information - Please complete the application information below
Primary Participant Name Name Change of Primary Participant
Other Participant Name Name Change of Other Participant
Previous Mailing Address City State Zip Code
New Mailing Address City State Zip Code
Previous Actual Address City State Zip Code
New Actual Address City State Zip Code
SECTION 3: Withdrawal Section - Please select applicable box
Primary Participant Other Participant
Name of Participant withdrawing from the program
Please note that withdrawal of the primary participant will remove this record and all other participants within this file from the program.
SECTION 4: Security Word - Please provide your security word below
Security Word:
You may contact our office for your hint to your security word.
SECTION 5: Affirmation of Participant
I hereby affirm under penalties of perjury that all information provided on this application is true and correct.
Signature of Participant Date
Please return the completed NYS Department of State
Change/Withdrawal Notice to: Address Confidentiality Program
P.O. Box 1110, Albany, NY 12201-1110
OR return to ACP via Fax at: (518) 474-0709
DOS-1931-f (Rev. 09/18) Page 2 of 2
NYS Department of State
Address Confidentiality Program
P.O. Box 1110
Albany, NY 12201-1110
Phone: (518) 474-7306
Toll Free: (855) 350-4595
Fax: (518) 474-0709
Email: [email protected]
Web: www.dos.ny.gov/acp