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                                  Nebraska Change of Address Request                                                                               FORM

                                                           for Individual Income Tax Only                                                          22A
  Social Security Number           

 Nebraska ID Number 

       Previous Name and Mailing Address                                      New Name and Mailing Address
 Your First Name and Initial                         Last Name          Your First Name and Initial                        Last Name

  If a Joint Return, Spouse’s First Name and Initial Last Name          If a Joint Return, Spouse’s First Name and Initial Last Name

  Street or Other Mailing Address                                       Street or Other Mailing Address

  City                                               State     Zip Code City                                               State                   Zip Code

  Reason for Request

       Under penalties of law, I declare that I have examined this request, and to the best of my knowledge and belief, it is correct and complete.

 sign
       Duly Authorized Signature                                                                       Date                                        Phone Number
 here
       Email Address

                                                               Instructions
       Email Address. By entering an email address, the taxpayer acknowledges that DOR may contact 
       the taxpayer by email. The taxpayer accepts any risk to confidentiality associated with this method of 
       communication. DOR will send all confidential information by secure email or the State of Nebraska’s 
       file share system.

                                                      You may fax this request to 402-471-5927, or
                         mail to: Nebraska Department of Revenue, PO Box 98911, Lincoln, NE 68509-8911.
                                                           Please keep a copy for your records.
                                                                                                                                                   8-548-1996 Rev.   9-2021
                                                                                                                                                   8-548-1996 Rev. 11-2016