Arizona Form                                                                                          EFFECTIVE DATE
                                                                                Change of Address
                       822                                                                                                   M M D D 2 0                   Y Y

                       Use this form to notify the Arizona Department of Revenue of a change in your mailing address.
                                       Submit separate forms for home and business addresses.  Please type or print.

Check each box for the forms affected by this change:

 1                    Individual income tax returns (Arizona Forms 140, 140A, 140EZ, 140PY, 140NR, 140PTC, 141AZ)

                       Check this box if your last return was a joint return and you are now establishing a residence 
                       separate from the spouse with whom you filed that return.

 2                    Business returns (Arizona Forms 99, 99T, 120, 120A, 120S, 141AZ, 165)

 3a                  Name (Individuals:  first name, middle initial, last name)                                           3b Your Social Security Number

                                                                                                                          3c Employer Identification Number

 4a                  Spouse’s Name (first name, middle initial, last name)                                                4b Spouse’s Social Security Number

 5                   Prior Name (Complete this line if the name(s) has/have changed since last filing.)

 6a                  Old Address (number and street or PO Box)                  Apt./Suite 6b Spouse’s Old Address (number and street or PO Box)           Apt. No. 
                                                                                              (Complete line 6b only if different from address on line 6a.)

                     City, Town or Post Office                                             City, Town or Post Office

                     State or Province            ZIP or Postal Code                       State or Province                 ZIP or Postal Code

                     Country (if foreign address)                                          Country (if foreign address)

 7                   New Address (number and street or PO Box)                             Apt./Suite

                     City, Town or Post Office    State or Province                                    ZIP or Postal Code Country (if foreign address)

                     Your Signature                                                        Spouse’s Signature

    PLEASE SIGN HERE                                                                          
                     Date Date

                                                  Mail to:  Arizona Department of Revenue
                                                                                PO Box 29086
                                                               Phoenix, AZ  85038-9086

ADOR 10173 (16)