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Transfer of . Responsibilities .. Corporate to Personal/Employee Assumption of Liability rev10/15107 This fonv, will allow you to transfer billing responsibilities for a Verizon Wireless mobile telephone number currently held by your employerto you. 1. Complete all'the applicable fields below. 2. If you are eligible, or required, to change your calling plan to a consumer plan, please review the available calling plans on the Verizon Wireless website at verizonwireless.com. Select an appropriate calling plan and make necessary changes before submitting this request.. Provide the new calling plan information by completing the fields in the Calling Plan Change section below. The change will become effective once the transfer of liability is complete. 3. Read the terms and conditions of this Transfer of Billing Responsibilities Form. 4. Read and accept the Terms and Conditions of the Verizon Wireless Customer Agreement. You may obtain a copy of the Customer Agreement from your Organization or Verizon Wireless representative or online at verizonwireless.com (enter in Customer Agreement in the search field). 5. When returning this form via e-mail you must click the box above the signature line below to acknowledge your electronic acceptance of these terms. Save a copy of the form and upload it to the Verizon Wireless Secure Document Gateway at httns:// b2b. verizonviireless .com /tbmb /formuploader/ (address must be manually typed in to your browser). The form should then be e- mailed to WFMWESTSATSUPPORT @VERIZONWIRELESS.COM. Relinquishing party a -mails will only be accepted from the Organization's email domain. Once the form is received, a confirmation e-mail notice will be sent to the requester's e- mail box. An email must be received from both the relinquishing and assuming parties to ensure that each party has accepted these terms. 6. 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:949- 286 -8548 Note: Completion timelines for the Assumption of Liability re guest is 3 -5 business days. Account Information (Assuming Customer) Wireless Number to be Transferred: 511 Create New Billing Account: Yes ® No ❑ Assuming Customer Name: L ° �� ' i1e Add to Existing Account Number if appli cable : Billing Address: No PO Boxes a 9 L6 �r> cow �r i V 2 Date of Birth: - 7/1 - 7 1 I ip(p Social Security M Billinq Address Cont: E -Mail Address: trdty. }e ta7 ®afll.c city: State: QV. Zip Code: c) 7 4 a7 Driver's License Number: State: Primary Address for Use (if different than billing) Note: No P.O. Boxes: Home Phone: - City: State: _ J Zip Code: - Work Phone: t - tE,62 -4ct�5 • Calling Plan Name: aRo Home Airtime Minutes: I Monthly Access Fee: Personal/Em • Upon processing of the transfer of billing respon-rhrrrfr a new oersonal account will be established for you, for this mobile telephone number for which you agree to assume all financial respons • Establishment of your new personal account is c lation above will be used in conjunction with that credit check. A deposit mz • You will be required to accept a one -year cont /+! / ;existing contract, then the remainder of the existing contract term will carryover to yoi • You may be subject up to a $175 Early Terming infer of Billing Responsibilities and the Customer Agreement. • If you are receiving discounted monthly access is discount is based on your organization's agreement vdth Verizon Wireles d in accordance with your organization's agreement. You agree that, if yc -- - --- not be permitted to terminate your service without being liable for such Early Terrr q from a discount adjustment to which your organization has agreed. — ° 4– • To continue to receive your organization's mor or Line RYL) Process. You can check for eligibility and register for an employee discs • You understand that certain information relabn number and total monthly charge may be released to your organization. • Verizon Wireless reserves the right to require I f a review of your employment status reveals that you are not, or are no longer, an a right to remove this discount and move you to a commercial) available callin our line term commitment. Of you received this form electronically and are r wledge your electronic acceptance of these terms and the Customer Agreement. An emi•� g parties to ensure that each party has accepted these terms. Si ned: v-- rnn .u,,,.,. Date: I z 2y O rganization • The account identified must be current (no past due balance) before Verizon Wireless can transfer it to another party. • 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. ❑If you received this form electr 'tally and are returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these term . A email-must ust be re a ed fro the relinquishing and assumin arties to ensure that each a has acce ted these to s. Si ned: Title: M