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              DELAWARE DIVISION OF REVENUE        REQUEST FOR CHANGE                                                               WREQ                
              PO BOX 830                                                                                                           0089-99
              WILMINGTON, DE 19899-0830     *DF60316019999*                                                                                            
                                                                                 DF60316019999                                                         
    00899909000000000000012311200000000000000000000000000                                                                                              
                                                                                                                                                       
              ACCOUNT NUMBER                BUSINESS FEIN OR SSN                 CHANGE: BUSINESS FEIN OR SSN EFFECTIVE DATE       REASON FOR CHANGE   
         0-000000000-000                                                                                                                               
    BUSINESS MAILING ADDRESS                                                            CORRECT BUSINESS LOCATION ADDRESS                              
                                                                                 NAME                                                                  
                                                                                 ADDRESS                                                               
                                                                                        T I C Y                              STATE ZIP CODE            
                                                                                                                                                       
                                                                                        CORRECT MAILING ADDRESS IF DIFFERENT FROM ABOVE                
                                                                                        NAME                                                           
                                                                                        ADDRESS                                                        
                                                                                        T I C Y                              STATE ZIP CODE            
                                                                                                                                                       
                                                                                 TELEPHONE NUMBER                                                      
              AUTHO Z I R E I S   D GNATURE                                      EMAIL ADDRESS                               DATE                      
                                                                                                                                                       
                                                    Withholding
                                            Request for Change Form
  Use this form to make corrections or changes to your name, address, account number or taxable year-ending date. Also 
  use this Request for Change form if you have gone out of business and indicate the date your business ceased operations.

    Please  Note:  The  Withholding  Request  for  Change  form  only  makes  changes  to  your  withholding 
    account  in  our  Business  Master  File.  If  you  need  to  make  similar  changes  to  your  Corporate,  Sub  S 
  !Corporate  and/or  License  accounts,  please  complete  the  Corporate  Request  for  Change  form,  the  Sub  S 
  Corporate  Request  for  Change  form  or  the  License  Request  for  Change  form  respectively  for  each  type  of  tax.

                                            Step-by-Step Instructions
  Step 1: Please enter your information as it appears on the Division of Revenue’s current records

    Box A.        Account Number

    Box B.        Business Name and Address – Please enter the business name and location address that the Delaware 
                  Division of Revenue currently lists as your business name and location address.

  Step 2: 

   Field 1.       Account Number Change – If you wish to change the information in Box A, please enter your correct                                   
                  accountnumber in Field 1. Otherwise, leave Field 1 blank.
   Field 2.       Effective Date – Please enter the date you would like this Request for Change form to go into effect. 
   Field 3.       Reason for Change – Please enter the reason you are submitting this Request for Change form (i.e. out   
                  of business, incorporated, moved).
   Field 4.       New Business Location Address – If you wish to change the information in Box B, please enter your     
                  correct location address in Field 4. Otherwise, leave Field 4 blank.
   Field 5.       New Mailing Address – Please enter your correct business mailing address.

  Step 3: Sign and date the form. Mail to the address listed on the form or fax to 302-577-8203.

  If you have any questions, please call the Delaware Division of Revenue Business Master File Section at 302-577-8778.