Address Change Request Form

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KENTUCKY LABOR CABINET
Division of Workers Compensation Funds
Steven L. Beshear
Larry L. Roberts
Payment Branch
Governor
Secretary
Suite 4, 1047 U.S. Highway 127 South
Frankfort KY 40601
Robert L. Whittaker
Director
Telephone: (502) 564-5467
FAX: (502) 564-5112
SFAC
ADDRESS CHANGE REQUEST FORM
Please fill out all information completely.
Sign, date and mail form to:
Kentucky Labor Cabinet
Division of Worker’s Compensation Funds
1047 US HWY 127 South - Ste. 4
Frankfort, KY 40601
Please allow up to 4 weeks for the address change to take effect.
CLAIM NUMBER:
CLAIMANT’S NAME:
SSN#
ADDRESS:
TELEPHONE:
SIGNATURE OF PAYEE
DATE
An Equal Opportunity Employer M/F/D

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