1.	FaithLife Financial Policy Number(s):*

2.	Title, select one that applies
	Mr. Mrs. Ms. Miss Rev. Other, please specify

3.	Name* Please provide your first name, middle initial and surname

4.	Former Name*

5.	Marital Status* Please check one that applies
	Married Separated Divorced Single

6.	Email address

7.	Phone number(s):* Enter at least 1 response.
	Home:   Business:

8.	Does this name change involve a return to your maiden name? If yes, no supporting documentation is required. Simply submit this form and we will process your request.
	Yes No

	FaithLife Financial 470 Weber Street North Waterloo ON N2J 4G4 PH: 1-800-563-6237 Fax: (519) 886-0350 Email: moreinfo@faithlifefinancial.ca