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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
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
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