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03 03
DELAWARE DIVISION OF REVENUE REQUEST FOR CHANGE New Booklets Will Be Issued
04 PO BOX 830 for Business FEIN 04
05 WILMINGTON, DE 19899-0830 *DF62215019999* or SSN Changes Only 05
06 DF62215019999 06
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09 CHANGE: TAX YEAR ENDING DATE BUSINESS FEIN OR SSN CHANGE: BUSINESS FEIN OR SSN EFFECTIVE DATE REASON FOR CHANGE 09
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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
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21 TELEPHONE NUMBER 21
22 AUTHORIZED SIGNATURE EMAIL ADDRESS DATE 22
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