Form Mf-629 - Change Of Name/address Form
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1MF-629
Indiana Department of Revenue
State Form 49089
Check all that apply:
Change of Name/Address Form
□
(R4 / 6-13)
Name Change
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Do not use this form to report changes in ownership.
Address Change
□
□
Location:
Physical
Mailing
Previous Name and/or Address
Taxpayer Name
DBA
Address
City
State
Zip Code
New Name and/or Address
Taxpayer Name
DBA
Address
City
State
Zip Code
Please provide all license numbers to which the above change applies.
1. Taxpayer Identification Number (TID): ______________________________
2. Special Fuel License Number: ____________________________________
3. Gasoline Distributor’s License Number: _____________________________
4. Indiana Prepaid Sales Tax License Number: _________________________
5. Indiana Aviation Fuel Excise Tax License Number: ____________________
Taxpayer Identification Number (TID): _______________
Date Signed: _______________________________
Signature: ____________________________________
Printed Name: _____________________________
Title: _________________________________________
Telephone Number: _________________________
Email: ________________________________________
For assistance, call (317) 615-2625 or email the Fuel Tax Section at fetax@dor.in.gov.
Please mail the completed form to: Indiana Department of Revenue
Fuel Tax, Bonds and Licensing Section
P.O. Box 6114
Indianapolis, IN 46206-6114
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Parent category: Financial