Form Mf-629 - Change Of Name/address Form October 2003
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1MF-629
SF# 49089
Indiana Department of Revenue
(10-03)
Change of Name/Address Form
Do not use this form to report changes in ownership.
Check all that apply:
Name Change
Previous Name and/or Address
Address Change
Taxpayer Name:
DBA Name:
Address:
City:
State:
Zip Code:
New Name and/or Address
Taxpayer Name:
DBA Name:
Address:
City:
State:
Zip Code:
Please provide all license numbers to which the above 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:
TID:
Date Signed:
Telephone Number:
(
)
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Parent category: Financial