Form Mf-629 - Change Of Address Form
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1INDIANA DEPARTMENT OF REVENUE
CHANGE OF ADDRESS FORM
INDIANA REVENUE FORM
MF-629
Rev. 01/00
State Form 49089
Old Address
Company Name:
DBA Name:
Address:
City:
State:
Zip Code:
New Address
Company Name:
DBA Name:
Address:
City:
State:
Zip Code:
Please provide ALL license numbers to which the above address change applies:
1.
TID:_____________________________
2.
Special Fuel License Number: ______________________
3.
Gasoline Distributor's License Number: _________________
4.
Indiana Prepaid Sales Tax License Number:______________________
Signature
Typed or Printed Name
Title
Date Signed
Telephone Number
(
)
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Parent category: Financial