State Form 56842                  Indiana Department of Revenue
         (R2 / 10-23)
                                          Business Address Change

Complete a Business Address Change form for each location or tax type.

Section 1
Business Tax Identification (TID) Number  Business Federal Employer Identifiction Number (FEIN) TID/Location Number

Tax Type
□ Retail Sales Tax (RST)          □ Withholding (WTH)
Name of Business

Current Business Location Address         City                         State                    ZIP Code

New Business Location Address             City                         State                    ZIP Code

Current Business Mailing Address          City                         State                    ZIP Code

New Business Mailing Address              City                         State                    ZIP Code

Current Legal Mailing Address             City                         State                    ZIP Code

New Legal Mailing Address                 City                         State                    ZIP Code

Email Address                                                          Phone

NOTE: This form can only be processed if signed by a Power of Attorney (POA) or Responsible Officer is listed on the account. 
Complete Form POA-1 or ROC-1 if you need to update information.

Please mail updated form to:
PO Box 6197
Indianapolis, IN 46206-6197
or
Fax: 317-615-2608

Signature of POA / Responsible Officer: _______________________________________                 Date:________________________

Printed Name of POA / Responsible Officer: ____________________________________