Enlarge image
04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82
03 DELAWARE DIVISION OF REVENUE New Booklets Will Be Issued 03
REQUEST FOR CHANGE
04 PO BOX 830 for Business FEIN 04
05 WILMINGTON, DE 19899-0830 *DF62215019999* or SSN Changes Only 05
06 DF62215019999 06
07 07
08 08
09 CHANGE: TAX YEAR ENDING DATE BUSINESS FEIN OR SSN CHANGE: BUSINESS FEIN OR SSN EFFECTIVE DATE REASON FOR CHANGE 09
10 10
11 ACCOUNT NUMBER CORRECT BUSINESS LOCATION ADDRESS 11
12 NAME 12
13 OUT OF BUSINESS ADDRESS 13
14 EFFECTIVE DATE CITY STATE ZIP CODE 14
BUSINESS MAILINGADDRESS
15 15
16 CORRECT MAILING ADDRESS IF DIFFERENT FROM ABOVE 16
17 NAME 17
18 ADDRESS 18
19 CITY STATE ZIP CODE 19
20 20
21 TELEPHONE NUMBER 21
22 AUTHORIZED SIGNATURE EMAIL ADDRESS DATE 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 54
55 55
56 56
57 57
58 58
59 59
60 60
61 61
62 62
63 63
64 64
04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82