Form 22a - Nebraska Change Of Address Request
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Nebraska Change of Address Request
FORM
22A
for Individual Income Tax Only
Social Security Number
Nebraska ID Number
Previous Name and Mailing Address
New Name and Mailing Address
Your First Name and Initial
Last Name
Your First Name and Initial
Last Name
If a Joint Return, Spouse’s First Name and Initial
Last Name
If a Joint Return, Spouse’s First Name and Initial
Last Name
Mailing Address (Number and Street or PO Box)
Mailing Address (Number and Street or PO Box)
City, Town, or Post Office
State
Zip Code
City, Town, or Post Office
State
Zip Code
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
Duly Authorized Signature
Date
Phone Number
Email Address
You may fax this request to 402-471-5927, or
mail to: Nebraska Department of Revenue, PO Box 98911, Lincoln, NE 68509-8911.
Please keep a copy for your records.
8-548-1996 Rev. 9-2014
8-548-1996 Rev. 10-2010
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Parent category: Financial