Legal Name Change Affidavit
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1
2Indiana Department of Revenue
FORM
Legal Name Change Affi davit
MCS-NC
State Form 50861
Motor Carrier Services Division
(R3 / 9-13)
1. Enter your Federal Employer Identifi cation Number (FEIN):___________________________________________
(Partnerships must have a FEIN number).
2. Enter your Social Security Number (SSN): _______________________________________________________
(Only if you are a sole proprietor and do not have an FEIN).
3. Enter your company’s previous legal name:
_________________________________________________________________________________________
4. Enter your company’s new legal name:
_________________________________________________________________________________________
5. Enter the name under which you were “Doing Business As” (DBA) only if it is different than your legal name:
_________________________________________________________________________________________
6. If your DBA has changed, enter your new DBA: ____________________________________________________
7. Enter your principal place of business street address:
_________________________________________________________________________________________
_________________________________________________________________________________________
8. Enter your telephone number: ______________________________
9. Enter the effective date of the legal name change (mm/dd/yyyy): ______________________
This form must be signed by an individual authorized to sign documents on behalf of the company listed above. Print or type
the name, in the space provided, of the authorized individual signing this return. This individual must sign, date, and enter
his/her title in the spaces provided.
I swear or affi rm that the information I have entered on this form is correct. I understand that making a false statement on
this form may constitute the crime of perjury.
___________________________________________________
__________________________________
Signature
Date Signed
___________________________________________________
__________________________________
Type or Print Name
Telephone Number
___________________________________________________
Title
Mail this form to:
Indiana Department of Revenue
7811 Milhouse Road, Suite M
Indianapolis, IN 46241-9612
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