7-104-1975 Rev. 9-2017 Supersedes 7-104-1975 Rev. 9-2015
Use Form 22A for individual income tax name/address changes.
Nebraska Change Request
You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Retain a copy for your records.
Indicate Type of Action Requested by Checking Appropriate Boxes Below
6 Cancellation
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.
Average Annual Tax Liability
Average is Based on:
Estimate Reported Amounts
Number of Months Used to Compute Average
8 Change in
Filing Frequency
7 Reinstatement
9 Change in Name and Address
If you are changing the names or addresses on your certificates, licenses, or permits (for example, due to a name change, relocation, or
correction, and not from a change in ownership or federal ID number), please complete the following information.
New Name and Mailing AddressNew Name and Location Address of Business
Request Permission to File Future Returns:
Monthly Quarterly Annually
If you have a change in the ownership of your business, or have obtained a different federal employer ID number, you must cancel your certificates,
licenses, and permits. The new entity must file a Nebraska Tax Application, Form 20, to obtain its own certificates, licenses, and permits.
Name and Location Address
Name and Mailing Address
5 Check All Tax Programs Affected by Request:
Sales Tax (01)
Retailer’s Use Tax (02)
Use Tax (04)
Prepaid Wireless Surcharge (19)
Income Tax Withholding (21)
Wholesale Cigarette Dealer (47)
Tobacco Products (56)
Unstamped Cigarette Transporter (63)
Waste Reduction & Recycling Fee (64)
Tire Fee (66)
Fiduciary Income Tax (23)
Corporation Income Tax (24)
Financial Institution Tax (24)
Partnership Income Tax (25)
Severance and Conservation Tax (45)
1 Nebraska ID Number 3 County of Business Location in Nebraska
2 Federal Employer ID Number 4 For Department Use Only
Please Do Not Write in This Space
Names on your Certificate, License, or Permit
Street or Other Mailing Address
City State Zip Code
Names on your Certificate, License, or Permit
Address (Number and Street)
City State Zip Code
Street or Other Mailing Address
City State Zip Code
Name Doing Business As (DBA)
Business Legal Name
Business Address (Number and Street)
City State Zip Code
Signature of Owner, Partner, Member, Corporate Officer, or Title Date Phone Number
Duly Authorized Individual
Litter Fee (67)
Lodging Tax (68)
Date of Last Transaction Location of Records
Month _______ Day ________ Year _______
Date of Reinstatement Location of Records
Month _____ Day _____ Year _____
Year the Account was
10 Is this Nebraska location within the city limits?
(1) Yes (2) No
11 Reason for Request
Email Address
Who Must File. A Form 22 should be led by any taxpayer who:
Has a name or address change;
Needs to correct, cancel, reinstate, or change a Nebraska tax certicate, license, or permit; or
Needs to change the ling frequency for sales and use tax, tire fee, lodging tax, or income tax withholding returns.
One request may be used to correct, cancel, or change more than one certicate, license, or permit held by the taxpayer for the
tax programs listed, provided the Nebraska ID number is the same. Nebraska Change of Address Request for Individual Income
Tax Only, Form 22A, should be used for individual income tax name and address changes.
When and Where to File. Mail to the Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903, or fax
to 402-471-5927, prior to the change.
Permanently Closing the Business. Form 22 should be led to cancel one or more of the tax programs listed in line 5.
You are required to le all tax returns for tax periods through the date of your last transaction, or the last wage payment made
by the date entered on line 6.
Employers who cancel their income tax withholding account should, within 30 days after discontinuing business, le a nal
Nebraska Reconciliation of Income Tax Withheld, Form W-3N, and attach the state copy of each Wage and Tax Statement,
Federal Form W-2, issued to each employee.
Specific Instructions
Line 1. Enter the Nebraska ID number which you hold or have previously held. Do not enter your Social Security number.
Line 2. Enter your federal employer ID number, if you hold one. If one has been applied for, enter “Applied For.” If no federal
employer ID number is held or has been applied for, enter your Social Security number.
Line 3. Enter the Nebraska county where your business is located.
Name and Address. Enter the name and address as last led with the Nebraska Department of Revenue (Department)
or which is printed on your present certicate, license, or permit. A new name and address should be entered in the area
immediately following line 9 of this request.
Line 5. Check the tax programs affected by this request. If there is a change in more than one program, check all
appropriate boxes.
Line 6. A taxpayer closing a business must request cancellation of the tax program. A taxpayer having a seasonal type of
business may request cancellation of the tax program for the period in which no business activity is conducted. Returns must
be led for all periods ending prior to the date of cancellation.
A change in ownership or type of ownership will require a new certicate, license, or permit. When possible, the
Nebraska Tax Application, Form 20, used to obtain a new certicate, license, or permit, should accompany or precede
this request for cancellation.
Line 7. A taxpayer who previously cancelled a tax program may have it reinstated provided no change in the business has
occurred which would require a new certicate, license, or permit.
Line 8. A taxpayer ling a sales tax, use tax, or tire fee return with a tax liability of $900 to $3,000 annually may request
a quarterly ling frequency. Those with a tax liability of less than $900 annually may request an annual ling frequency.
Taxpayers ling a lodging tax return and remitting $99 or less of tax annually may request to le an annual return. Employers
withholding less than $500 annually in state income tax may request to le an annual return, rather than quarterly returns.
Changes in ling frequency are not effective until approval has been received from the Department. The taxpayer must complete
and le all preidentied returns received for periods prior to the approval.
Line 9. Enter the new name and address. The location address box cannot contain a PO Box Number; it must show the street
address. If the taxpayer wants a return to be mailed to a preparer or another person, the name and mailing address should be
completed to show this change.
Line 11. Give a detailed explanation of the reason for this request. If there has been a change in ownership, give the name and
address of the new owner.
Signature. This request must be signed by the owner, partner, member, corporate ofcer, or other individual authorized to sign
by a power of attorney on le with the Department.