Form Ador 74-4004 - Department Of Revenue Update Card

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DEPARTMENT OF REVENUE UPDATE CARD
Use this card to provide notifi cation of changes to Transaction Privilge Tax (TPT) or withholding accounts. Please indicate any changes in the business that will
affect your licenses with the Department of Revenue. The license type and number, your taxpayer identifi cation number/social security number, and your signature
are required to authorize any changes. Please return this form along with your TPT or withholding return, or mail to License & Registration, PO Box 29032, Phoenix,
AZ, 85038-9032. A $12 state license fee is required to change the business name or location on your TPT license. Additional fees for city licenses vary by city
($1 to $25). You will be billed for underpayment of fees. If you have any questions, please call (602) 542-4576 in Phoenix, or (800) 643-6494 toll-free, in state.
License Number: _____________________________
TPT _____________________________
Withholding
1. Business name: _______________________________________________________
IF YOU NEED MORE WITHHOLDING COUPONS, circle the amount
2. Change business name to : ______________________________________________
needed per quarter:
3. Change business address to: ____________________________________________
3
6
9
12
15
18
21
CHECK HERE TO CANCEL YOUR LICENSE
Return your state Transaction Privilege Tax license and indicate
4. Change mailing address to: ______________________________________________
M M
/
D D
/
Y Y Y Y
the date you ceased doing business:
CHECK HERE IF YOU NEED AN APPLICATION FOR A NEW
5. Business phone: ____________________ Home phone: _____________________
LICENSE. New licenses are needed for Transaction Privilege
6.
Federal Employer I.D. or
Social Security Number: ______________________
Tax under the following conditions: change in business owner-
M M
/
D D
/
Y Y Y Y
M M
/
D D
/
Y Y Y Y
7. Suspend license from:
to:
ship, add/delete spouse (ownership), change to partnership/sole
owner/corporation, change in county location of business.
8. Add or delete city(ies) licensed for: ________________________________________
M M
/
D D
/
Y Y Y Y
9. Effective date of change:
Signature: _____________________________________________ Date: ___________________
ADOR 74-4004 (9/01) slw

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