Form 22 - Nebraska Change Request - 2013
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1
2Nebraska Change Request
Form
22
Use Form 22A for individual income tax name/address changes.
1 Nebraska ID Number
3 County of Business Location in Nebraska
Please Do Not Write in This Space
RESET FORM
PRINT FORM
2 Federal Employer ID Number
4 For Department Use Only
Name and Location Address
Name and Mailing Address
Names on your Certificate, License, or Permit
Names on your Certificate, License, or Permit
Address (Number and Street)
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
5 Check All Tax Programs Affected by Request:
Sales Tax (01)
Fiduciary Income Tax (23)
Wholesale Cigarette Dealer (47)
Litter Fee (67)
Retailer’s Use Tax (02)
Corporation Income Tax (24)
Tobacco Products (56)
Lodging Tax (68)
Use Tax (04)
Financial Institution Tax (24)
Unstamped Cigarette Transporter (63)
Other
Prepaid Wireless Surcharge (19)
Partnership Income Tax (25)
Waste Reduction & Recycling Fee (64)
Income Tax Withholding (21)
Severance and Conservation Tax (45)
Tire Fee (66)
Indicate Type of Action Requested by Checking Appropriate Boxes Below
If you have a change in the ownership of your business, or have obtained a different federal employer ID number, you must cancel your certificates,
licenses, and permits. The new entity must file a
Nebraska Tax Application, Form 20,
to obtain its own certificates, licenses, and permits.
Date of Last Transaction
Location of Records
6
Cancellation
Month _______ Day ________ Year _______
Date of Reinstatement
Location of Records
Year the Account was
7
Reinstatement
Cancelled
Month _____ Day _____ Year _____
Returns are Presently Filed:
Request Permission to File Future Returns:
8
Change in
Monthly
Quarterly
Annually
Monthly
Quarterly
Annually
Filing Frequency
Average Annual Tax Liability
Average is Based on:
Number of Months Used to Compute Average
$
Estimate
Reported Amounts
9
Change in Name and Address
If you are changing the names or addresses on your certificates, licenses, or permits (for example, due to a name change, relocation, or
correction, and not from a change in ownership or federal ID number), please complete the following information.
New Name and Location Address of Business
New Name and Mailing Address
Name Doing Business As (DBA)
Name
Business Legal Name
Business Address (Number and Street)
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
10 Is this Nebraska location within the city limits?
(1)
Yes
(2)
No
11 Reason for Request
Under penalties of law, I declare that I have examined this request, and to the best of my knowledge and belief, it is correct and complete.
sign
here
Signature of Owner, Partner, Member, Corporate Officer, or
Title
Date
Phone Number
Duly Authorized Individual
Email Address
You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Retain a copy for your records.
9-2015
7-104-1975 Rev.
Supersedes 7-104-1975 Rev. 10-2013
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