State Form 56842              Indiana Department of Revenue
             (9-19)
                                       Business Address Change 

Section 1
Tax Type:
□ Sales & Use Tax     □ Food & Beverage Tax     □ Withholding Tax     □ Corporate Tax     □County Innkeepers Tax     
□Other ________________________________

Section 2
Business TID              Business FID Business Contact Name           Doing Business As Name

Previous Address                       City                            State               ZIP Code

New Address                            City                            State               ZIP Code

Phone                                  Email

Previous Location Address              City                            State               ZIP Code

New Location Address                   City                            State               ZIP Code

Please mail updated form to:

PO Box 6197
Indianapolis, IN 46206-6197
or 
Fax # (317) 615-2608

Signature of Responsible Officer: ____________________________________________ Date:________________________

Printed Name of Responsible Officer: _________________________________________