Roc-1, Correct / Change Of Responsible Officer Information Page 2
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1
2INSTRUCTIONS
Correct/Change of Responsible Offi cer Information
NOTICE: All information, including the supporting documentation, must be provided
before the form will be considered to be a valid request.
If more space is needed to record your changes, you may attach a separate sheet.
Business Information Section
Please provide the following required information:
1. Federal (FEIN) and Indiana (TID) Identifi cation Numbers
2. Legal names of the entity submitting the change request
3. DBA (Doing Business As) Name of the entity
(if different from the legal name)
4. Business mailing address
Old Responsible Offi cer Information
Complete all applicable columns. This information is necessary to ensure we identify and
remove the correct individual.
Note: Supporting documentation establishing a separation date must be provided.
Documentation may include: Corporate Minutes, Registration Letter, Financial Documents
showing removal as a signatory of bank account, Affi davit from another offi cer; etc...
New Responsible Offi cer Information
Complete all applicable columns. This information is necessary to ensure we correctly
identify and add the new offi cer.
Note: Supporting documentation must be provided. Documentation may include: Cor-
porate Minutes, Financial Documentation showing the addition of individual as Signatory
of Bank Account, Affi davit from another offi cer; etc...
This change/correction must be submitted and signed by an existing owner, partner
or corporate offi cer before it will be accepted by the Department.
Note: The individual submitting this change form request cannot be the person to be
deleted as a responsible offi cer.
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