KANSAS DEPARTMENT OF REVENUE                                                                              800518
                                                 NAME OR ADDRESS CHANGE FORM

Individual
Current Name: _____________________________________________________________________________________________________________      Current SSN: ____________________________________
o I am changing my name. New Name: ____________________________________________________________________________________________________________________________________
o I am changing my address
_____________________________________________________ ______________________________________________ _____________________________________________________________________________________
Social Security Number                                Contact me by Home Phone Number                                          Old Email Address
_____________________________________________________ ______________________________________________ _____________________________________________________________________________________
Spouse Social Security Number                         Contact me by Cell Phone Number                                          Current Email Address
________________________________________________________________________________________________________________________________________________________________________________________________
New Name (Include spouse’s full name if filed jointly)
________________________________________________________________________________________________________________________________________________________________________________________________
New Address (street, city, state and zip code)
____________________________________________________________________________________________________________________________________________________ _______________________________________
Signature                                                                                                                                                           Date

Business
Current Business Name:________________________________________________________________________________________                 Current EIN/SSN:_____________________________________
o I am changing my business name. New Business Name:_________________________________________________________________________________________________________
o I am changing my DBA name. New DBA Name: _____________________________________________________________________________________________________________________
o I am changing my address:                           o Business Mailing Address                     o Business Location Address
o I am correcting my EIN:                             o New EIN ________________________________     o Old EIN __________________________________

This change will affect the following tax accounts:
o Retailers’ Sales Tax                                  o Dry Cleaning Surcharge                       o Tire Excise Tax
o Withholding Tax                                       o Liquor Drink Tax                             o Transient Guest Tax
o Consumers’ Compensating Use Tax                       o Liquor Enforcement Tax                       o Vehicle Rental Excise Tax
o Retailers’ Compensating Use Tax                       o Nonresident Contractor                       o Water Protection/Clean Drinking Water Fee
o Cigarette Vending Machine Permit                      o Privilege Tax                                o Charitable Gaming
o Corporate Income Tax                                  o Retail Cigarette License
Mailing Address:
________________________________________________________________________________________________________________________________________________________________________________________________
New Mailing Address (street, county, city, state and zip code)
________________________________________________ ___________________________________________________________________________________________________________________________________________
Contact me by Home Phone Number                                                                      Old Email Address
________________________________________________ ____________________________________________________________________________________________________________________________________________
Contact me by Cell Phone Number                                                                      Current Email Address

Location Address: Effective Date (mm/dd/yyyy):          ____________________________________________
______________________________________________________________________________________________________________________________ o Outside City Limits              o Inside City Limits
Old Location Address (street, county, city, state and zip code)
______________________________________________________________________________________________________________________________ o Outside City Limits              o Inside City Limits
New Location Address (street, county, city, state and zip code)
________________________________________________      _________________________________________________________________________________________________________________________________________
Contact me by Home Phone Number                                                                      Old Email Address
________________________________________________      ________________________________________________________________________________________________________________________________________
Contact me by Cell Phone Number                                                                      Current Email Address
___________________________________________________________________________________ _____________________________________________________________________________ __________________________
                       (Signature)                                                                   (Printed Name)                                                 (Date)
Mail to: KDOR - Taxpayer Assistance Center, PO Box 3506, Topeka KS 66625-3506 or fax to 785-296-2073. If you have questions about 
the completion of this form, call 785-368-8222.
DO-5 (Rev. 10-20)