R-6505 (1/16)
                                                                                   Mail to:
                            Individual Income Tax                                  Louisiana Department of Revenue
                                                                                   P.O. Box 201
                            Name and Address Change Form                           Baton Rouge, LA 70821
                                                                                   Fax: (225) 231-6205

You can also change your address through our Contact Us webpage at  https://esweb.revenue.louisiana.gov/ContactUs/
AddressChange.aspx

Check all the boxes that this change affects:                       Effective Date of Change: ____________________

 Your last individual income tax return was a joint return, and you are now establishing a residence separate from the spouse with 
 whom you filed that return.

 Address change

 Name change
Last Name                   First Name                                          MI Social Security Number

Spouse’s Last Name          Spouse’s First Name                                 MI Spouse’s Social Security Number

Former Last Name            Former First Name                                   MI

New Address
Street                                        Apt/Suite City                               State      ZIP

Old Address
Street                                        Apt/Suite City                               State      ZIP

Contact Person                                          Daytime Telephone Number 

Your Signature                                          Date        (mm/dd/yyyy)

Spouse’s Signature                                      Date        (mm/dd/yyyy)

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