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: ____________________12/12/16

 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
dksjfkdsghskdjgh                              akjsfjahsdfj                                 f 123-45-6789
Spouse’s Last Name                            Spouse’s First Name                      MI    Spouse’s Social Security Number
glsflskgdfjlksglj                             lkasjdlfj                                    j 123-45-6789
Former Last Name                              Former First Name                        MI
jflksjlkjlkdjlkjg                             kdjldkfjlkjf                             g

New Address
Street                                                   Apt/Suite City                              State      ZIP
akfjalkjdflkjg                                           12j       skladflaskjdf                         jf     kllkajf
Old Address
Street                                                   Apt/Suite City                              State      ZIP
sklfasjlfkj                                                12      aksjflakf                         12         skjdlafj

Contact Person                                                     Daytime Telephone Number 
akjflskdjf                                                         (123) 456-7890

Your Signature                                                     Date (mm/dd/yyyy)
                                                                   12/12/2016
Spouse’s Signature                                                 Date (mm/dd/yyyy)
                                                                   12/12/2016

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