Form 22 - Nebraska Change Request
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1FORM
Nebraska Change Request
ne
22
dep
• Read instructions on reverse side
of
nebraska
PLEASE DO NOT WRITE IN THIS SPACE
department
of revenue
1 Nebraska Identification Number
2 Federal Employer Identification or Social Security Number
3 County of Business Location in Nebraska
4 Business Classification Code (Department Use Only)
CURRENT NAME AND LOCATION ADDRESS
CURRENT NAME AND MAILING ADDRESS
Name as Shown on your Certificate, License, or Permit
Name as Shown on your Certificate, License, or Permit
Address (Number and Street, or Rural Route and Box Number)
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
5 Check Tax Programs Affected by Request
Lodging Tax (68)
Other
Income Tax Withholding (21)
Sales Tax (01)
Consumer’s Use Tax (04)
Fertilizer Fee (12)
Individual Income Tax (22)
Retailer’s Use Tax (02)
Wholesale Cigarette Dealer (47)
Fiduciary Income Tax (23)
Corporation Income Tax (24)
Tire Fee (66)
Tobacco Products (56)
Unstamped Cigarette Transporter (63)
Partnership Income Tax (25)
Waste Reduction & Recycling Fee (64)
Severance and Conservation Tax (45)
Financial Institution Tax (24)
Litter Fee (67)
CHECK TYPE OF ACTION REQUESTED
6
Termination, Complete Date of Last Transaction Information
Date of Last Transaction
Date of Last Wage Payment
Location of Records
Month ____ Day ____ Year ____ Month ____ Day ____ Year ____
If you have a change in the ownership of your business, you must terminate your certificates, licenses, and permits.
The new entity must file a Nebraska Tax Application, Form 20, to obtain its own certificates, licenses, and permits.
Year the account was
Date of First Transaction
Date of First Wage Payment
Location of Records
7
Reinstatement
cancelled___________
Month ____ Day ____ Year ____ Month ____ Day ____ Year ____
Returns are Presently Filed:
Request Permission to File Returns:
8
Change in Filing Frequency
Monthly
Quarterly
Annually
Monthly
Quarterly
Annually
Average Annual Tax Liability
Average is Based on:
Number of Months Used to
Compute Average
Estimate
Reported Amounts
$
9
Change in Name and Address
If you are not changing the ownership of your business, or obtaining a different federal identification number, you may change
the names and addresses as shown on your certificate, license, or permit by completing the following information.
NEW NAME AND LOCATION ADDRESS
NEW NAME AND MAILING ADDRESS
Name
Name
Address (Number and Street, or Rural Route and Box Number)
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
10
10
10
10
10 Reason for Request
Under penalties of law, I declare that I have examined this request, and to the best of my knowledge and belief, it is correct and complete.
sign
sign
sign
sign
sign
(
)
here
here
here
here
here
Signature of Owner, Partner, Member, Corporate Officer, or
Title
Date
Telephone Number
Duly Authorized Individual
Mail this request to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
PLEASE MAKE A COPY OF THIS FORM TO KEEP WITH YOUR RECORDS
11-99
7-104-75 Rev.
Supersedes 7-104-75 Rev. 12-97
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