Form R-6505 - Individual Income Tax Name And Address Change
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1R-6505 (1/16)
Mail to:
Individual Income Tax
Louisiana Department of Revenue
P.O. Box 201
Name and Address Change Form
Baton Rouge, LA 70821
Fax: (225) 231-6205
You can also change your address through our Contact Us webpage at
https://esweb.revenue.louisiana.gov/ContactUs/
AddressChange.aspx
12/12/16
Check all the boxes that this change affects:
Effective Date of Change: ____________________
Your last individual income tax return was a joint return, and you are now establishing a residence separate from the spouse with
whom you filed that return.
Address change
Name change
Last Name
First Name
MI
Social Security Number
dksjfkdsghskdjgh
akjsfjahsdfj
f
123-45-6789
Spouse’s Last Name
Spouse’s First Name
MI
Spouse’s Social Security Number
glsflskgdfjlksglj
lkasjdlfj
j
123-45-6789
Former Last Name
Former First Name
MI
jflksjlkjlkdjlkjg
kdjldkfjlkjf
g
New Address
Street
Apt/Suite
City
State
ZIP
akfjalkjdflkjg
12j
skladflaskjdf
jf
kllkajf
Old Address
Street
Apt/Suite
City
State
ZIP
sklfasjlfkj
12
aksjflakf
12
skjdlafj
Daytime Telephone Number
Contact Person
akjflskdjf
(123) 456-7890
Your Signature
Date
(mm/dd/yyyy)
12/12/2016
Spouse’s Signature
Date
(mm/dd/yyyy)
12/12/2016
6680
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Parent category: Financial