Enlarge image | RESET PRINT 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 Mailing Address (Number and Street or PO Box) Mailing Address (Number and Street or PO Box) City, Town, or Post Office State Zip Code City, Town, or Post Office State Zip Code 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 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. 11-2016 8-548-1996 Rev. 9-2014 |