Form R-6505 - Individual Income Tax Name And Address Change Form
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1R - 6505 (01/06)
Individual Income Tax
Name and Address Change Form
Check all the boxes that this change affects:
Effective Date of Change: ____________________
Your last individual income tax return was a joint return, and you are now establishing a residence
separate rate from the spouse with whom you filed that return.
Address change
Name change
Your name
Social Security Number
last
first
mi
Spouse’s name
Social Security Number
last
first
mi
Former Name
last
first
mi
New Address
Street
Apt/Suite
City/State
Zip
New Suite
New City/State
New Zip
New Address
New Street
Old Address
Street
Apt/Suite
City/State
Zip
Old Suite
Old City/State
Old Zip
Old Addtress
Old Street
Contact person and daytime telephone number
__________________________________________________________(______)_______-_______________
Your signature
Date
Spouse’s signature
Date
Request must be mailed or faxed to:
Louisiana Department of Revenue
P. O. Box 201
Baton Rouge, LA 70821
Fax Number: 225-219-2348
6680
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Parent category: Financial