Change of Address FormReturn to the Information About Change of Ownership Page Full Owner Name * (As listed on check) First Name Last Name Any Applicable Titles Email * Confirm Email * Your Name (if you are not the owner) If not previously provided, please email changeofaddress@ballardexpl.com documentation establishing your relationship with the Account Owner for Ballard’s review. First Name Last Name Phone Number * So We May Contact You With Any Questions (###) ### #### Last Four Digits of Social Security Number or Tax ID Number * For Identity Verification Owner Number This should be no more than 8 numbers, and is listed to the left of the name section of your check Previous Address for Verification * Address 1 Address 2 City State/Province Zip/Postal Code Country New Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Is Either Address the Location of Your Mineral Rights * ------------------- Yes No I Don't Know I Have Sold the Property Location of my Mineral Rights, but Retained Ownership of the Mineral Rights * ------------------- Yes No I Don't Know If you have sold your property, but reserved your mineral rights, supporting documentation may be required. We will contact you if necessary to obtain supporting documentation. Comments E-Signature * I, authorize Ballard Exploration Company, Inc. and/or its affiliates/subsidiaries to change the address on my owner account. * TERMS OF ACCEPTANCE OF SIGNATURE I, the requestor for this Change of Address, warrant the truthfulness of the information provided in this submission. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. Step 1: Check the box below* By checking this box and typing my name below, I am electronically signing this Change of Address Form. Step 2: Type in your name in the box below. A signature is required by all parties listed on the account. I agree to the the Terms Thank you! We have received your change of Address Form and your address will be automatically updated. We will only contact you if we have any questions or concerns!
