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Please complete the following form if you have moved and would like to notify us of your new address. This change will require a signature. If you have access to a printer, upon making the appropriate changes, you may print the form, sign it and return it to Luzerne Bank, 118 Main Street, Luzerne, PA 18709 or Fax it to us at (570) 331-2358.
You MUST fill in ALL information or your information will NOT be processed!

CUSTOMER INFORMATION
Customer Name:

PREVIOUS INFORMATION
Address:
City:   State:   Zip:
SSN Number:
Phone (home):   (business):

NEW INFORMATION
Address:
City:   State:   Zip:
Phone (home):   (business):

ADDITIONAL HOUSEHOLD MEMBERS
Please list any additional account holders who are moving to the new address indicated above.

ACCOUNT NUMBERS
Please list below ONLY those account(s) you have with LNB that you DO NOT want to reflect this change:

SIGNATURE (Required): ___________________________________________

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