Cardholder Change Account Form: Citibank Government Travel Card Program
Cardholder Change Account Form: Citibank Government Travel Card Program
Cardholder Change Account Form: Citibank Government Travel Card Program
Save
Clear
Instructions:
Section I of this form can be completed by the cardholder or APC to make personal
information changes to a cardholders account. Section II must be completed by the
APC to make changes to a cardholders account and card type, cash access, or spending
limits. Fields with an asterisk are required. Fax completed form to 1-605-330-9900.
Attention:
Fax:
605-330-9900866-312-8586
SSN#
This section is for an account holder with a restricted account who would like to apply for an account upgrade to a standard account. The account holder
must sign this box thereby authorizing the bank to obtain a credit report. Cardholder name and account number are required in Section A (above).
By signing below, I, the cardholder, hereby authorize the bank to obtain credit reports on me as described in the
cardholder agreement. PLEASE RETAIN A COPY FOR YOUR RECORDS.
Account
Upgrade
Cardholder*
APC
Date*
Date
In addition to completing section A, if you are an APC, complete this section to correct a cardholders name. Please include both prior and new
information. Name changes require legal documentation for processing and will result in issuance of a new card. (Individually Billed Accounts only).
Examples of legal documentations include, but are not limited to, a copy of a Marriage Certificate and/or Identification Card.
Name
Prior
New
First Name
Last Name
MI
First Name
Last Name
MI
In addition to completing section A, if you are an APC , complete this section to change the billing address of an account.
Change of
Address
Address Line 1
Address Line 2
City or APO/FPO
State
Zip/Postal Code
Country
In addition to completing section A and/or B above, complete this section to update a commercial telephone/fax number or email address.
Telephone and fax numbers should include international country codes.
New
*Required Items. Form will be returned if required items are not completed.
Citi Transaction Services
2013 Citibank (South Dakota), N.A. All rights reserved. Citi and Arc Design and Citibank are service marks
of Citigroup Inc. or its affiliates, used and registered throughout the world.
1093189 05/13 1 of 4
8505
Save
Clear
Completed
By*
Title
APC
Commercial Phone
Date
Cardholder
Commercial Fax
Signature
Section II: Change Cardholder Account, Card Type, Cash Access or Spending Limit Information to be completed by APC
Central
Account
Number
Account
Hierarchy
Cash
Access
Temporary
Credit/
Cash Limit
Increase
Completed
By*
To be completed by APC
To be completed by APC. Specify the complete hierarchy level number that pertains to your organization.
HL1
HL2
HL3
HL4
HL5
HL6
HL7
Complete this section to add the ability for the cardholder to obtain cash. The amounts allowed will depend on the account type (standard or
restricted)
Cash Access
No Yes
Complete this section to temporarily increase the credit/cash limits on an account. The length of time for temporary limit increases are as follows:
Standard accounts: Up to 12 months
Restricted accounts: Up to 6 months
Limits
Credit Limit
Start Date*
End Date*
Cash Limit
Start Date*
End Date*
___________________________________________
Type or Print Name
Title
___________________________________________
Signature
Date
APC
Commercial Phone
Cardholder
Commercial Fax
*Required Items. Form will be returned if required items are not completed.
1093189 05/13 2 of 4
8505
Save
Clear
Use this form to make changes to a cardholder account. Sections I and II may be completed independently of each other.
Who:
When:
Complete this form when there is a need to make a change to a cardholders personal information (Section I) or
account, card type, cash access, or spending limits. Fields with an asterisk are required.
How:
Section I:
Change
Cardholder
Personal
Information
This section
is to be
completed
by the
Cardholder
or the APC
Cardholder Name, Signature and Date: Applicant types or prints name, signs and dates the form
thereby authorizing the bank to obtain a credit report. Applicant is required to complete section B
including name and account number. Account Upgrade requests are processed at the end of each
month. Notification of decline will be sent via letter to the applicant
Check Box to Close Account: Please check box and provide reason for closure
Cardholder Name*: Enter name of cardholder (as it appears on the card) requesting change
Cardholder Account Number*: Indicate cardholders 16-digit account number
B. Account Upgrade
C. Name
Prior: Provide cardholders previous name (first, last, MI), rank/grade and military status
New: Provide cardholders new name (first, last, MI), rank/grade and military status
D. Change of Address
New Billing Address: Provide cardholders new address where future bills should be sent
E. Telephone, Fax & Email
New Telephone, Fax & Email: Provide cardholders new home, commercial and fax telephone
numbers to include area code and international country code (Do not provide DSN). Also,
provide cardholders new email address.
F. Completed By*
Type or Print Name: Type or print the name of the person completing this form
Title: Select whether person completing this form is an APC or Cardholder
Commercial & Fax Phone: Provide Commercial telephone and fax numbers of the person completing
this form. Be sure to include the area code and international country code (Do not include DSN).
Signature: Signature of the person completing this form
Date: Date of signature
Section Il:
Change
Cardholder
Account,
Card Type,
Cash
Access or
Spending
Limit
Information
This section
is to be
completed
by the APC
1093189 05/13 3 of 4
8505
Save
Clear
1093189 05/13 4 of 4
8505