KANSAS OWNERSHIP CHANGE FORM 
                                                                                                                    RCN - FOR OFFICE USE ONLY 

Name of business: _____________________________________________________           EIN:    ___ ___ __ ___ ___ ___ ___ ___ ___ 

Complete the following information so your customer profile can be maintained with the most current information. You may 
copy this form i fmore space is needed.  Important—If a business fails to report or pay appropriate state taxes, any individual 
who is responsible for the tax authorizes the Secretary of Revenue to research the credit history of the business or that 
individual. 

Check the appropriate box:       ˆ   Adding a name                      ˆ  Removing a name

__________________________________________________               _______________________________________________
Printed full proper name of Owner, Partner, or Corporate Officer  Signature of Owner, Partner, or Corporate Officer 

SSN / EIN       (Check one) ____________________________________ Title ____________________________________________ 

Home address (street, city, state, zip code) __________________________________________________________________________

Home phone_____________________  Email  ___________________________________  Percent of Ownership ______ 

Do or did you have control or authority over how business funds or assets are spent?    ˆ Yes    ˆ N

Date you became the owner, partner, corporate officer or LLC member; or the effective date to remove your name as the owner
partner, corporate officer or LLC member of this business.  Month ________ Day ________ Year ________ 

Check the appropriate box:       ˆ   Adding a name                      ˆ  Removing a name

__________________________________________________               _______________________________________________
Printed full proper name of Owner, Partner, or Corporate Officer  Signature of Owner, Partner, or Corporate Officer 

SSN / EIN       (Check one) ____________________________________ Title ____________________________________________ 

Home address (street, city, state, zip code) __________________________________________________________________________

Home phone_____________________  Email  ___________________________________  Percent of Ownership ______ 

Do or did you have control or authority over how business funds or assets are spent?    ˆ Yes    ˆ N

Date you became the owner, partner, corporate officer or LLC member; or the effective date to remove your name as the owner
partner, corporate officer or LLC member of this business.  Month ________ Day ________ Year ________ 

Check the appropriate box:       ˆ   Adding a name                      ˆ  Removing a name

__________________________________________________               _______________________________________________
Printed full proper name of Owner, Partner, or Corporate Officer  Signature of Owner, Partner, or Corporate Officer 

SSN / EIN       (Check one) ____________________________________ Title ____________________________________________ 

Home address (street, city, state, zip code) ___________________________________________________________________________  

Home phone_____________________ Email ___________________________________ Percent of Ownership ______                       %  

Do or did you have control or authority over how business funds or assets are spent?    ˆ Yes    ˆ No  

Date you became the owner, partner, corporate officer or LLC member; or the effective date to remove your name as the owner,  
partner, corporate officer or LLC member of this business.  Month ________ Day ________ Year ________ 
CR-18 (Rev. 81-)9 Send this form and any payments to: Kansas Department of Revenue, PO Box 3506, Topeka KS 666      25-3506 
                                         or FAX to 785-291-3614. For assistance call 785-368-8222.