Form Fit Ca - Request To Cancel Account
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1FIT CA
Rev. 10/13
Reset Form
Request to
Please do not
Cancel Account
use staples.
FIT account number
Ohio charter or license number
FEIN/SSN
Use only UPPERCASE letters.
Reporting person's name
/
/
Please cancel my FIT account effective (MM/DD/YY)
Reason for cancellation:
Business closed. Date (MM/DD/YY):
Bankruptcy. Case no:
Organizational change. New FEIN:
Sold/merged business. Please provide the following information regarding the company or person to whom the business was sold
or with whom the business merged:
Name
Address
FEIN
FIT account number
Effective date of sale/merger (MM/DD/YY)
SIGN HERE (required)
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in
this matter to fi le this request to cancel this account.
Signature
Date (MM/DD/YY)
Name
Title
Contact person: The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of Tax
Representative (Ohio form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov.
First name
M.I.
Last name
Street address (number and street)
City
State
ZIP code
Telephone
Fax
Title
E-mail
Please send this request to: Ohio Department of Taxation, Business Tax Division,
Financial Institutions Tax Unit, P.O. Box 2476, Columbus, OH 43216-2476 or fax to (206) 666-4462.
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Parent category: Financial