State of Tennessee	
Court (Must Be Completed)	
County (Must Be Completed)	

Case Number:

Your name:

ATTACHMENT TO
ORDER TRANSFERRING WIRELESS PHONE ACCOUNT 
Confidential Information

DO NOT FILE THIS FORM IN THE COURT FILE  

ATTENTION PROTECTED PERSON: This form should not be filed in the court file. 

If the judge ordered that a transfer of a wireless phone account from the restrained person’s name into your name, then:

a)	Complete this form
b)	Send this form and a copy of the Order Transferring Wireless Phone Account to the   wireless service provider (service provider). 

To be completed by Protected Person:

1

The service provider is (name of company): __________________________________________

2

The current account holder (name of restrained person): ________________________________

3

The new account holder (your name):  ______________________________________________

Your contact information (Only the service provider will use this information to contact you to set up your account):

a.	The best phone number to reach you at is (make sure it is not the phone number of the restrained person or a number on his/her account):

b.	Another phone number to reach you at is (make sure it is not the phone number of the restrained person or a number on his/her account): 
_________________________________________________________________________

c.	Your private e-mail address that the restrained person cannot use: __________________________________________________________________________

d.	Your mailing address that the restrained person cannot use or get to:

SEND the Order Transferring Wireless Phone Account AND THIS FORM to the Wireless Carrier
To find out where to send these forms, go to the Tennessee Secretary of State’s website at: https://tnbear.tn.gov/Ecommerce/FilingSearch.aspx and search for your service provider. The account(s) CANNOT be transferred to you if you do not send these forms to the service provider.

ATTENTION WIRELESS SERVICE PROVIDER

Pursuant to Tennessee Code Annotated 36-3-621, the person’s contact information listed in #3 above is CONFIDENTIAL and must not be disclosed to the person listed in number 2   .

04/02/2019			
Form #OP2018-4