Please enter and describe any changes that are necessary. Print the form ( If this form does not print correctly (caused by some version(s) of Internet Explorer browser software), note changes on a separate piece of paper.) when complete and attach it to a signed letter on your institution's letterhead requesting the change.

NOTE: For the purpose of collecting Annual Report data, please disregard Recent Activity and Financial Information sections listed for your institution on the web page.

Upon completing the Modification Form, it should be mailed to:

Massachusetts Division of Banks
1000 Washington Street, 10th Floor
Boston, MA 02118-6400

ATTN: Depository Institution Supervision

If you have any questions regarding banks, please call Alexis Leahy at 617-956-1545. If you have any questions regarding credit unions, please call Andrea Cipolla at 617-956-1532.

Financial Institution: