ࡱ> U ^Ubjbjnn 5daaP  88888LLL8LLLtzxA<} KKKKKKK$mN#QKu8K88;LI"I"I"f88KI"KI"I"G0(KP>fH$KQL0LH@QiQH(KQ8(KdI"KKI"LQ B : Transfer of Billing Responsibilities E-mail/Faxback Form Government Agency to Personal/Employee Assumption of LiabilityThis form will allow you to transfer billing responsibilities for a Verizon Wireless mobile telephone number currently held by your employer to you. Complete all the applicable fields below. If you are eligible, or required, to change your calling plan, please review the available calling plans on the Verizon Wireless website at verizonwireless.com. After selecting a calling plan, complete the fields in the Calling Plan Change section below. Read the terms and conditions of this Transfer of Billing Responsibilities Form. Read the Verizon Wireless Customer Agreement. E-mail this form by clicking the box to the left of the appropriate signature line, save a copy and email it to wfmfederalaol@verizonwireless.com. E-mails will only be accepted from your Organizations email domain. Once the form is received, a confirmation e-mail notice will be sent to the requesters e-mail box. If e-mail process is not available, return this form via Fax, have both parties sign and print at the bottom of this form and fax this form to:910-794-7718 Note: Completion timelines for the Assumption of Liability request is 3-5 business days. Account Information (Assuming Customer) Wireless Number to be Transferred:  FORMTEXT       FORMCHECKBOX Create New Billing Account:  FORMTEXT       FORMCHECKBOX   Assuming Customer Name:  FORMTEXT      Add to Existing Account Number:  FORMTEXT       Account Number:  FORMTEXT       Billing Address: (No PO Boxes)  FORMTEXT      Date of Birth:  FORMTEXT Contact assuming custumer for this DOBSocial Security #:  FORMTEXT Contact assuming custumer for SS# Billing Address (Cont):  FORMTEXT      E-Mail Address:  FORMTEXT       City:  FORMTEXT      State:  FORMTEXT      Driver s License Number:  FORMTEXT Contact assuming custumer for DLNState:  FORMTEXT       Zip Code:  FORMTEXT      Home Phone:  FORMTEXT      Work Phone:  FORMTEXT      Calling Plan Change - If Required (Assuming Customer) Calling Plan Name:  FORMTEXT Customer requred to provide or purchase new device. Home Airtime Minutes:  FORMTEXT       Line Term:  FORMCHECKBOX  FORMTEXT       12 Months  FORMTEXT        FORMCHECKBOX 24 MonthsMonthly Access Fee:  FORMTEXT      Organization Release of Liability (Relinquishing Customer)The individual signing this Transfer of Liability on behalf of Organization represents that they have the legal capacity to bind Organization. Organization remains responsible for all charges incurred until the line is transferred. By signing this form, or checking the box below, Organization agrees to release liability for the mobile telephone number indicated above. If returning via email, the Organization representative must include their name and date.  FORMCHECKBOX   FORMTEXT       If returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these terms.Signed:  FORMTEXT      Title:  FORMTEXT Senior Procurement OfficerName:  FORMTEXT Sherrene V. Moore,Date:  FORMTEXT8xyz{|- N     @ A K L   ,.0hj~ƽƷƽƱxkx[xxxxjhnCJUmHnHujJhnCJUjhnCJUhn5CJOJQJ\^Jhn5CJOJQJ\^Jhn5OJQJ\^Jhn hnCJ hnCJhn5CJ\ hnCJhn5OJQJ^JhjhnUhn5CJOJQJ\^Jhhn5CJOJQJ\^J":y{| < = WMCC  & F$If $If^kdH$$Ifl0<|)  @    0*4 lap $$If]a$ $$If]a$=  z $$If^a$ckdvI$$Ifl4     |)*    0     *4 laf4 h$If^h  & F$If    $$Ifa$qkdJ$$Ifl4     |)*       0     *4 laf4p ~ PRfhjtv&(HJ^`bҷҪҝҐ҃uh)h)CJmHnHujNhnCJUjONhnCJUj(MhnCJUjLhnCJUj@LhnCJUhnCJOJQJhn hnCJjhnCJUmHnHujhnCJUj'KhnCJU- $$Ifa$vkdK$$Ifl4     0|)        0     *4 laf4*8sg $$Ifa$gd| $$Ifa$gd) $$Ifa$vkdM$$Ifl4     0|)      0     *4 laf4468:ln"$8:<FH|~~j{RhnCJUjRhnCJUjPhnCJUjhnCJUmHnHujlPhnCJUhnCJOJQJh|CJmHnHuj7OhnCJU hnCJjhnCJUh)CJmHnHu,8:<ulll $$Ifa$kdO$$Ifl4     F<|)      @   0     *    4 laf4Js $$Ifa$gd) $$Ifa$vkdTQ$$Ifl4     0|)      0     *4 laf4*,@BDNPjlɼɢɕɈ{ɢlhn5OJQJ\^JaJjUhnCJUjUhnCJUjThnCJUhnCJOJQJjhnCJUmHnHujcShnCJU hnCJh)CJmHnHuh)h)CJmHnHujhnCJUjRhnCJU&RbYYYY $$Ifa$kdS$$Ifl4     \!|)_            0     *4 laf4@uh $$If^a$kdV$$Ifl4     F|)         0     *    4 laf4>@Bjl 468BDFH`b~DFZγئΖ؉Ζ|ΖjzYhnCJUjYhnCJUjhnCJUmHnHujWhnCJUh|h|CJmHnHujaWhnCJUjhnCJU hnCJhnhn5OJQJ\^J hn5CJOJQJ\^JaJ,@BDFuh $$If^a$ $$1$Ifa$gd$ $$1$Ifa$qkdV$$Ifl4     |)*       0     *4 laf4p FHJl}r} $$1$Ifa$ $$If^a$tkdIX$$Ifl4     0 |)r   r    0     *4 laf4Z\^hjlnABCDSTUV`a   οΊ΂΂uocScjhnCJOJQJU^JhnCJOJQJ^J hnCJj`\hnCJUjhnUhn5CJOJQJ\^Jhn5OJQJ\^Jhn5CJOJQJ\^JhnOJQJ^Jhn5OJQJ\^JaJhn hnCJjhnCJUmHnHujhnCJUjYhnCJUln} $$If^a$tkdbZ$$Ifl4     0 |)r   r    0     *4 laf4[AB{{{q $If^ & F $If^skd[$$Ifl4     |)*       0     *4 laf4p BC0,akd\$$Ifl4     |)*    0     *4 laf4 $$If^a$ckd[$$Ifl4     |)*    0     *4 laf4 ",.>@TVXHHܴܐܴyhWܴUU!hCJOJQJ^JmHnHu!h|CJOJQJ^JmHnHu%j^hnCJOJQJU^Jhn!h2e~CJOJQJ^JmHnHu%j]hnCJOJQJU^JhnCJOJQJ^J hnCJ*jhnCJOJQJU^JmHnHujhnCJOJQJU^J%jg]hnCJOJQJU^J0HHxh[[ $$If^a$$$If^a$gdvkdO^$$Ifl4     0H|)    4    0     *4 laf4$$If^a$gd2e~      Current Corporate Account Number:  FORMTEXT      Personal/Employee Assumption of Liability (Assuming Customer)Upon processing of the transfer of billing responsibilities, a new personal account will be established for you, for this mobile telephone number for which you agree to assume all financial responsibility. Establishment of your new personal account is dependent upon a credit check. Some of your personal information above will be used in conjunction with that credit check. A deposit may be required to establish this account. Your new personal account requires an annual service agreement and you may be subject up to a $175 Early Termination Fee pursuant to the terms and conditions of both the Transfer of Billing Responsibilities and the Customer Agreement. . You understand that certain information relating to your service, including your name, your mobile telephone number and total monthly charge may be released to your organization. Verizon Wireless reserves the right to require proof of your employment (Government Agency ID badge or pay stub). If a review of your employment status reveals that you are not, or are no longer, an employee of your organization, Verizon Wireless reserves the right to remove this discount and move you to a commercially available calling plan or to a non-discounted service plan for the remainder of your line term commitment. FORMCHECKBOX  FORMTEXT       If returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these terms. 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