REV-854 (TR) MOD 10-22 
FEIN/ADDRESS CHANGE 

PURPOSE                                                           2. Enter changes in the fields marked "New" on the right-hand 
This form is used to request Federal Entity Identification Number    side of the coupon including FEIN, effective date of changes 
changes and address updates for corporation tax accounts. These      and address. If the address has changed, enter the entire 
changes may be made electronically on myPATH at 
mypath.pa.gov.                                                       new address on the form. 
   NOTE: This form may not to be used for making Legal            3. Signature, title, date, email address and telephone 
   Name changes or filing frequency changes.  The filing             number must be provided by a representative of the 
period is determined by the filing period begin and end dates        corporation. 
reported on the corporate tax return. For information on          *If you are updating the Federal Employer Identification Number 
corporation name changes, contact the Department of State,        (FEIN), the REV-854 must be accompanied by the FEIN 
Corporation Bureau at 717-787-1057.                               “assignment letter” issued by the IRS. 
1. Enter account information including Corporate Account ID, 
                                                                  Fax or email to: 
   *Federal Employer Identification number (FEIN), corporation 
   name and complete mailing address.                                Fax: 717-787-3708 
                                                                     Email: ra-btftregisfax@pa.gov

                                                  FILL IN FORM USING ALL CAPS.
                    DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD.  ENTER DATES AS MMDDYYYY.
                      PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS COUPON.

         REV-854 (TR) MOD 10-22                   FEIN/ADDRESS CHANGE                           DEPT USE ONLY

   Corporation Name                                                  Account ID

   Current EIN                                                    New EIN          Effective Date of Changes

   Current Street Address First Line                              New Street Address First Line

   Current Street Address Second Line                             New Street Address Second Line

   Current City                       C. State Current ZIP        New City                          N.State New ZIP

                Signature                         Title                                         Date
                       Please sign after printing.
                Email                                                              Telephone

   Reset Entire Form                                                                                        PRINT FORM