Form 22 - Nebraska Change Request - 2009
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1Nebraska Change Request
FORM
22
• Form 22A is to be used for individual income tax name/address changes
• Instructions on reverse side
PLEASE DO NOT WRITE IN THIS SPACE
PRINT FORM
RESET FORM
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)
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name(s) as Shown on your Certificate, License, or Permit
Name(s) 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 All Tax Programs Affected by Request:
Sales Tax (01)
Tobacco Products (56)
Corporation Income Tax (24)
Lodging Tax (68)
Retailer’s Use Tax (02)
Financial Institution Tax (24)
Unstamped Cigarette Transporter (63)
Other
Consumer’s Use Tax (04)
Partnership Income Tax (25)
Waste Reduction & Recycling Fee (64)
Income Tax Withholding (21)
Tire Fee (66)
Severance and Conservation Tax (45)
Fiduciary Income Tax (23)
Litter Fee (67)
Wholesale Cigarette Dealer (47)
INDICATE TYPE OF ACTION REQUESTED BY CHECKING APPROPRIATE BOX(ES) BELOW
If you have a change in the ownership of your business or have obtained a different federal employer identification number, you must cancel your
certificates, licenses, and permits. The new entity must file a Nebraska Tax Application, Form 20, to obtain its own certificates, licenses, and permits.
6
Cancellation, Complete Date of Last Transaction Information
Date of Last Transaction
Location of Records
Month _______ Day________ Year _______
Date of Reinstatement
Year the account was
Location of Records
7
Reinstatement
Month _____ Day _____ Year _____
cancelled __________
Returns are Presently Filed:
Request Permission to File Future 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 changing the names or addresses as shown on your certificates, licenses, or permits (for example, due to a name change, relocation,
or correction, and NOT from a change in ownership or federal identification number), please complete the following information.
NEW NAME AND LOCATION ADDRESS
NEW NAME AND MAILING ADDRESS
Name Doing Business As (DBA)
Name(s)
Business Legal 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 Is this Nebraska location within the city limits?
(1)
YES
(2)
NO
11 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
here
Signature of Owner, Partner, Member, Corporate Officer, or
Title
Date
Telephone Number
Duly Authorized Individual
E-Mail Address
You may fax this request to (402) 471-5927, or mail this request to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 98903, LINCOLN, NE 68509-8903
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
8-2009
PLEASE MAKE A COPY FOR YOUR RECORDS
7-104-1975 Rev.
Supersedes 7-104-1975 Rev. 8-2008
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