NAME OR ADDRESS CHANGE FORM
Individual
Current Name: Current SSN:
I am changing my name. New Name:
I am changing my address
Social Security Number Contact me by Home Phone Number Old Email Address
Spouse Social Security Number Contact me by Cell Phone Number Current Email Address
New Name (Include spouse’s full name if led jointly)
New Address (street, city, state and zip code)
Signature Date
Business
Current Business Name: Current EIN/SSN:
I am changing my business name. New Business Name:
I am changing my DBA name. New DBA Name:
I am changing my address: Business Mailing Address Business Location Address
I am correcting my EIN: New EIN Old EIN
This change will aect the following tax accounts:
Retailers’ Sales Tax Dry Cleaning Surcharge Tire Excise Tax
Withholding Tax Liquor Drink Tax Transient Guest Tax
Consumers’ Compensating Use Tax Liquor Enforcement Tax Vehicle Rental Excise Tax
Retailers’ Compensating Use Tax Nonresident Contractor Water Protection/Clean Drinking Water Fee
Cigarette Vending Machine Permit Privilege Tax Charitable Gaming
Corporate Income Tax Retail Cigarette License
Mailing Address:
New Mailing Address (street, county, city, state and zip code)
Contact me by Home Phone Number Old Email Address
Contact me by Cell Phone Number Current Email Address
Location Address: Eective Date (mm/dd/yyyy):
Old Location Address (street, county, city, state and zip code)
Outside City Limits Inside City Limits
New Location Address (street, county, city, state and zip code)
KANSAS DEPARTMENT OF REVENUE
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______________________________________________________________________________________________________________________________ o Outside City Limits o Inside City Limits
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Contact me by Home Phone Number
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Old Email Address
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Contact me by Cell Phone Number Current Email Address
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(Signature) (Printed Name) (Date)
Mail to: KDOR - Taxpayer Assistance Center, PO Box 3506, Topeka KS 66625-3506 or fax to 785-296-2073. If you have questions about
the completion of this form, call 785-368-8222.
DO-5 (Rev. 10-20)
800518