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Tiple moves. Instructions: Mail or fax this form to the address or fax number above. See page 2 for additional instructions. DMV USE ONLY RECEIVED DATE (mm/dd/yyyy) REFERENCE NUMBER CHECK NUMBER CHECK AMOUNT SHIPPER New Shipper Location Shipper Address Change ID NUMBER (VAHPS ID, FEIN, OR SSN) GOVERNMENT MOVE (check one) STATE CONTACT PERSON NAME LOCAL TELEPHONE NUMBER FAX NUMBER COMPANY NAME MAILING ADDRESS P. O. BOX, SUITE NUMBER (if applicable) CITY STATE ZIP CODE VA JURISDICT.
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