Form Cat Es - Request To Change Election Status Page 2

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CAT ES
Rev. 3/13
Request to Change
Please do not
Election Status
use staples.
Contact person: The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of Tax
Representative (form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov.
Your fi rst name
M.I.
Last name
Home address (number and street)
City
State
ZIP code
Telephone
Fax
Title
E-mail
Please send this application to:
Ohio Department of Taxation
CAT Division – CAT ES
P.O. Box 16158
Columbus, OH 43216-6158

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