BMI
Date:
LEGAL CHANGE OF NAME FOR BMI AFFILIATED WRITER
____________________
Broadcast Music, Inc. Performing Rights Administration This is to advise BMI that I have legally changed my name. Please have all checks, statements and other correspondence sent to me at my address as indicated below. MY CURRENT BMI WRITER CONTRACT NAME: _________________________________________________________ WRITER ACCOUNT NUMBER: ________________________
PSEUDONYMS (AKA) CURRENTLY LISTED FOR ME: __________________________________________________________________________________ MY SOCIAL SECURITY NUMBER IS: ________________________ MY NEW LEGAL NAME IS: _________________________________________________________________________________ First Name Middle Name Last Name Suffix (ex. Jr/Sr) OLD SIGNATURE ______________________________________
NEW SIGNATURE ______________________________________
ADDRESS:
________________________________________________________________ Street Apt. No. ________________________________________________________________ City State Zip
Home Phone No.:
______________________
Email Address: __________________________
Thank you for noting your records. This form must be accompanied with:
• Court authorized document supporting name change (marriage certificate, divorce decree, etc) • Completed IRS W9 form